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Why do we need to start using prevention and wellness in orthopedic physical therapy? Well, to start, the science overwhelmingly supports it. The research continually tells us that being proactive with your health can reduce likelihood of pain and dysfunction both now and later in a person’s life.
However just having science to support prevention and wellness in orthopedics doesn’t mean that physical therapists are practicing this way. And there may be some important factors likely contributing to this lack of progress:
This puts many physical therapists in a mode of survival themselves. If we are simply trying to survive and make it through each day, how do physical therapists make the change to support themselves and their clients in a meaningful and sustainable way?
The key to practicing prevention and wellness in orthopedic physical therapy, is probably a lot less glamorous than you thought. It’s remembering that every single movement counts.
Instead of trying to overhaul a person’s lifestyle on the first visit, begin by supporting small baby steps towards positive change. This momentum will carry through and lead to larger changes over time.
Additionally…you’ll want to begin to practice these habits of Integrative and Lifestyle Medicine in your own life. It doesn’t have to look perfect. Start the same way your patients do, with baby steps.
Maybe you can even take it a step further. Sign up for a course in Integrative and Lifestyle Medicine to level up your knowledge and confidence so you feel confident to guide people into a new and healthier way of living in the world.
The status quo of orthopedic physical therapy can do some really wonderful things for people. And there are also some enormous gaps that leave people struggling, suffering, and in pain longer than they need to be.
Are you ready to break free from the status quo? Do you want to learn how to implement tools of prevention and wellness in orthopedic physical therapy settings?
Check out this podcast to learn more about it.
You can also join our FB group for PT and OT entrepreneurs who are over the hustle culture and looking for a different way that doesn’t involve getting burned out.
For those of you that prefer video, watch this discussion about prevention and wellness in orthopedic physical. You can also listen to it on our podcast, Living Well.
Additionally, check out the chapter she co-wrote with Dr. Elizabeth Dean, “Orthopedics” in the book, Integrative and Lifestyle Medicine in Physical Therapy.
Anne Söderlund, PhD, is a professor in Physiotherapy with behavioral medicine profile at the School of Health, Care and Welfare, Mälardalen University, Västerås, Sweden. She is also an affiliated professor at Arcada University of Applied Sciences in Helsinki, Finland. She is a leader of a multidisciplinary group, BeMe-Health, of 20 researchers. Her research area is on prevention, treatment, and evaluation of health problems from a behavioral medicine perspective in the physiotherapy framework. Her research focuses on the individual’s behavior and ability to function in everyday life at different ages. She has more than 100 published scientific articles. She is a member of the European Pain Federation Academy Board. She is also an Editor-in-Chief for the European Journal of Physiotherapy.
00:00 Dr. Ginger Garner: Hello everyone, this is Ginger Garner and I am here with one of the wonderful authors from the book Integrative and Lifestyle Medicine in Physical Therapy and I’m honored to be interviewing her today and spending a little bit of time with her.
So before we get started, I’d like to introduce her and then we’re going to just jump right in. I’d like to welcome Dr. Anne Soderlund. She is a professor in Physiotherapy with Behavioral Medicine profile at the School of Healthcare and Wellfare in Sweden. She is an also an affiliated professor at Arcada University of Applied Sciences in Helsinki, Finland.
She is a leader of a multidisciplinary group, Be-Me Health which consists of 20 researchers. Her research area is focused on prevention, treatment, and evaluation of health problems from a behavioral medicine perspective in a physiotherapy framework.
Her research focuses on something that’s super important for us in PT, the individual’s behavior and the ability to function in everyday life at different ages. She has more than 100 published scientific articles, but that’s sink in for a moment. She is a member of the European Pain Federation Academy Board and also editor-in-chief for the European Journal of Physiotherapy.
Welcome Dr. Soderlund.
01:28 Dr. Anne Soderlund: Thank you.
01:29Dr. Ginger Garner: I’m so glad that you’re here today.
Before we get started or as we get started, I always have this question on the forefront of my mind and that is in learning more about you. What brought you to Physiotherapy?
01:44 Dr. Anne Soderlund: Yeah, that is an interesting part. I was 18 years old and I just heard what Physiotherapy, Physical Therapy. I was living in Finland at that time. Then what is that? What do they do? I went to search some information through a study supervisor. She said, let’s see what I was thinking about you when you were 15 years old. Then she looked at, okay, I recommended you to be a Physical Therapist or Physiotherapist, that time three years before.
Oh, this is my thing, I will be a Physiotherapist. So that was it.
02:30 Dr. Ginger Garner: Wow. I’ve often said this about our high schools and the way we choose our educational path in the United States and I wish that we had more specific guidance and recommendations and of course it’s been a few years since I was in high school but the field of PT came up in my kind of realm also at that same time but your story is so much more interesting. In that, counselor, someone who is guiding you in that direction; whereas for me it was just a classmate who was interested in Physical Therapy. I didn’t even know that existed. I thought law school was a good choice, but I love your story.
The duration of time that you have been in Physiotherapy is incredible and tell me how you have just seen things evolve and change because I’m sure there’s been a number of things that you could say. Oh, that’s one of my favorite things about being PT or this is a thing that I see that’s I mean, this gives us a snapshot of your time and physiotherapy.
How have things shifted?
03:55 Dr. Anne Soderlund: Yeah, that is an interesting story actually too because I had my education, Physiotherapy program in Finland and I think the Nordic countries had very similar programs at that time and I remember this was 1978 in Christmas time and I remember our Vice Counselor, she said in the last talk to us that you go out there now and make yourself not needed anymore.
So make yourself not needed anymore. That was kind of a prevention, that was a preventional thought and then in the beginning of 80’s there was obviously more money in the system in healthcare system because there was a lot of preventional programs going on also, in Finland, at least. But then the money disappeared in 90s somewhere, and then we started to direct only to the people who were already sick.
So 90s was not so much about that, what is so deep in my heart, the prevention of lifestyle coaching. The prevention, it is so important.
05:49 Dr. Ginger Garner: Absolutely it is and I’ve spent a bit of time, it’s one of my biggest passions is advocacy and making sure that people have access to physical therapy and when we the United States, is not a model for that necessarily, but the Nordic countries have done so many wonderful things to pace themselves ahead of us in terms of prevention and wellness. Then you mentioned in the 90s kind of thing shifting, what do things look like now? You’re in Sweden now, right?
06:26 Dr. Anne Soderlund: Yep
06:27 Dr. Ginger Garner: So what do things look like now in terms of prevention and wellness there?
06:33 Dr. Anne Soderlund: Yeah the government is talking about quite a lot about prevention but the money isn’t there. So they just want to support and they just want to identify the areas where we need to be much better to prevent sickness and illness and also different kinds of trauma of course. The government is constantly calling for research money and maybe not so much in the education, but at least research money is not going to the prevention area, unfortunately. Very few projects, maybe 10% or 9% gets money for those kind of things.
07:32 Dr. Ginger Garner: So are you finding that there are the levels of chronic non-communicable chronic disease and pain are also increasing maybe not similarly to the US or maybe. Is that what is happening there?
07:40 Dr. Anne Soderlund: Yeah they are increasing, still increasing, they have been increasing quite a lot. I think they have been increasing slowly in the beginning of 90s, and then faster and faster. So that is so true.
08:00 Dr. Ginger Garner: So we’re sharing similar struggles where our healthcare systems, you know I think at the end of the day, our vision is to be aligned with wellness and prevention and behavior change but kind of where the rubber meets the road – that part is not happening.
And I think that and we mentioned this and this kind of takes us into your chapter in the book and the overarching theme of the book which is trying to take a full circle path back to integrative principles of lifestyle medicine principles to help people and practitioners. And the book is really about physical therapists doing that, but the Centers for Disease Control (CDC) and the World Health Organization (WHO) all have the same, you know impetus to press all healthcare providers to be screening for these lifestyle medicine and lifestyle habits that we know contribute to chronic disease development and pain. I know in the United States we spend nearly twice as much on healthcare as any other nation but we are we rank among the last.
We are last among the 12 wealthiest nations in medical outcomes. So we need integrated and lifestyle medicine. Sweden needs it. The world needs it. You know the United States tends to run a really poor track record on that kind of thing. So the book was/is timely.
09:35Dr. Anne Soderlund: Can I say something? This pandemic we had, it showed even more clearly that we need to do something. We need to do so much more in this area. Smoking, overweight – these kind of problems that are preventable. If there is a little bit more support from the government side – at least that’s what I think.
10:08 Dr. Ginger Garner: Right, and we need to make sure to be absolutely accessible. We can do a lot to improve accessibility and because there are so many of us as physiotherapists. I think that we can do a lot and we’re pretty ideally suited because we can spend more time with our patients. We can talk to them about these interventions.
So that let me put to this question how did you, what drew you into using integrated and lifestyle medicine, or at what point did you that it kind of click and you went – this is what we really need to be focusing on here?
10:43 Dr. Anne Soderlund: I think it is based on my original start from the end of the education. What the Vice Counselor said about make yourself not needed in the world. So I have always been there somehow, for example asking patients: do you smoke or how much do you drink and what do you eat and do you do exercise?
That is we always ask that of course but but they have always been, it’s kind of my bottom, blade where I am standing, and then it’s you the more I know the more I read about health and sickness the more I acknowledge for myself and others too that these are important parts in everywhere where we work. It doesn’t it doesn’t need to be musculoskeletal pain, or musculoskeletal problems. It can be neurological problems. It can be psychosomatic problems. Psychiatry problems. Everywhere, this is everywhere.
And we are so, as you said, we are so made for this. To support, to coach people to other places not where they are.
1 2:25Dr. Ginger Garner: Right, meeting them where they are which, yeah maybe in picking the thing which is the easiest for them to start changing so it’s not overwhelming for them and I think the same thing applies to physio and physical therapists trying to apply integrative and lifestyle medicine because for many of them it might be a little scary concept something. What if their school really didn’t have a strong you know health promotion class? Or because a lot of programs all all programs I say would probably have something you know, along the lines of that, applying integrative and lifestyle medicine. So what do you think some of the biggest challenges or maybe the biggest challenge for our PT’s are today?
13:23Dr. Anne Soderlund: I think one of the biggest challenges is to heighten our own self efficacy to believe us, the belief that we can do this. We can do this. We have the tools. There, I think, there is no physical therapists in the world who doesn’t negotiate goals with the patient and that is one of the behavior change techniques. But you need to be aware of what you are doing. It is not just the goal setting. It is it is more than that.
So I think one of the biggest challenges is to get the highest self efficacy to do this thing to to talk with the patients about lifestyle problems and lifestyle factors and then, also of course we need to need to send the patients further. We cannot say, “I don’t know how to to support patients to tostop smoking or or stop drinking. I don’t know how to do.” There are other people who can do that, but we need to ask the questions and then help them to that kind of support.
14:52 Dr. Ginger Garner: I want to pull out that one thing that you said because if you if you’re a student physical therapist listening or even if you’ve been a practitioner for 10 years and this is a shift of way of thinking and a practice for you, I think the very first thing is one of things you said to reiterate is to just be prepared to screen for all of these things screen for nutrition, stress management, physical activity, environmental influences which includes smoking tobacco cessation and minimizing other harmful environmental pollutants like estrogen or endocrine disruptors, for example.
Did I get everything on the list? And relationships, focusing on relationships. And that last one brings up another important point I wanted to draw out of what you said to emphasize which is self efficacy and that applies to not just the improving patient self efficacy but believing, like you’ve mentioned, believing that we are able to deliver these services which might mean additional training, maybe it means sticking your nose in the book for a little bit longer, or a book for a little bit longer.
Because in order to increase someone else’s self efficacy I think you also have to believe in yourself and believe that you can too and so in a way practicing integrative and lifestyle medicine is a deeper form of self care because it’s not just something academic that you learn in a book you’re really learning to apply this stuff. And it is the most efficacious if you’re applying it to yourself first. Kind of putting your own O2 mask on first and then it’s easier to apply it. The research also shows that our patients are more likely to listen to us if we are actually some sort of role model.
Dr. Anne Soderlund: Yeah, so true.
16:54 Dr. Ginger Garner: Yeah so with speaking to those challenges because we have two things there. One – healthcare providers and you can speak to how physiotherapists feel, what burnout rates look like in Sweden. In the United States we are crippled by a few things, student loans and debt, high productivity requirements. So seeing more and more patients in less time with low-re reimbursement and then not having the funds to if you want to start a health promotion program or a wellness-based program the question is always who’s going to pay for that.
So, I think my question would be to you and I would love to get your insight on the challenges faced in Sweden by physiotherapists because in doing that we know we learn about the other wicked problems in the world and how to solve those so how do you think we can overcome or navigate the challenges that you see with PT’s either in Sweden or globally?
17:58 Dr. Anne Soderlund: That is a big question, yeah.
18:10 Dr. Ginger Garner: We can start with, oh I was just going to mention, even starting with something like behavior change or stress management. That’s one of the main areas where PT’s perceived themselves, not the public necessarily, but PT’s themselves, perceived themselves to be less capable.
18:36 Dr. Anne Soderlund: Yeah if you, but that is also a question. Well, in our education programs – how do we define the stress? What is stress? If we are defining the stress, one of the stressors is having pain, for example. We PT’s, we are meeting pain patients, at least in Sweden, 80% of the patients that PT’s are meeting, they are having pain, musculoskeletal pain. So that is a stress, that is a stressful situation to have pain.
Just be aware, I don’t know maybe we should do more in our education in a way that defines these concepts that we are using. So that we, for example, what to do with stress. What is stress? That we are not looking at it as that is nothing for me. That we could see behind it, to see that it is not actually so complicated at all. It is everything. We have a lot of stressors around us and in our daily lives. Everybody has it and sometimes they are too high and sometimes they are normal level and sometimes nothing.
So I think that is one thing that we need to, we need to maybe discuss more. Also, how do you see, what is stress for you? What is stress for you? How do you see that? It will then naturally progress towards uncovering what we should do. Okay every PT knows how to how to teach patients to relax and that is one of the treatments.
20:46 Dr. Ginger Garner: One of the foundations, yeah I think that also in the US and this is not in just the US, this is globally. Kelly McGonagall who has her PhD, she did a TED talk. This was several years ago and the slant that she took on stress was that she looked at research which tracked people’s longevity and their mortality was dependent on how they perceived stress. If they perceived stress as something that was going to break them that was going to overcome them then they were more likely to die earlier. But if they perceived stress as something that could make them stronger.
In other words, instead of just distress, eustress, that it could build them up. That it could take them to a better place. They actually had improved longevity which I think the conversation could simply start with that. What is eustress? What is what is distress? Then breaking down your question of what is stress and how do we know when we’re practicing you know what we’d call grit or resilience.
How do we know when resilience is good or bad in ourselves and in our patients? It’s a really good question because some of the things that we perceive as stress oftentimes we could use things like cognitive behavioral therapy (CBT) or ACT (Acceptance and Commitment Therapy) to reframe you know cognitively restructure how people are thinking about things and of course again it comes right back to us again because you know we want to reframe the way we think about things too. So again it’s self-care and self-medicine at the highest degree.
I think that looking at how to deconstruct if I’m hearing you correctly and I completely agree with it, if we can deconstruct what people perceive and define as stress and guide them and not tell them but guide them towards a manageable solution. Sometimes it’s just guiding them in a way that helps them find their own answers which I think is most effective. It’s certainly in the tobacco association literature, people are more likely to quit smoking if they come up with the reasons for why versus us telling them.
23:28 Dr. Anne Soderlund: I’m thinking about when we meet the patient and we are talking with them for the first time, we want to know why they are here and what the problem is. How do they see the problem. If we are listening with the “right ears” then you can find the factors causing the stress. Also, if the person is kind of turning emotionally or trying to emotionally manage it, trying to manage the behavior. As…I am trying to do this and I’m trying to do that and maybe the behavior strategies are not always very good. Maybe they they should be formed to some other way, more active, also but still you can you can hear in the story when you are meeting the patient that what the stressor is and how the patient sees to that, and how overwhelming it is for them.
24:34 Dr. Ginger Garner: On my intake forms, I just include a stress a brief stress inventory and I also ask them about time. Because stress and time management tend to go together. If people feel like they don’t have a lot of time then their ability to manage that stress kind of falls off and then their stress radar you know, kind of ticks up from there.
So I think I hear if I had to give it a percentage, I think in at least 40 percent maybe even half of my patients that’s what rises to the top. We end up talking about how they’re able to fit into their daily schedule what I’m asking them to do. It could be stress management, it could be something to do with pelvic health, or whatnot.
When I circle back and say let’s break down your home program into a way that you can fit it into your life realistically I always see a look of relief. Like, okay. Because we’re trying to usher them towards that it could be a small tiny behavior change right or it could be a big one but we get there the same way by making these little tiny steps towards and sometimes it’s just acknowledging that our patient may only have five minutes to three times a day maybe to do what we would like for them to do. It’s our job to figure out how we can fit it into their day, which that alone could lower their stress perception.
26:13Dr. Anne Soderlund: That’s where the WHO has done good work in their latest report about physical activity and sedentary behavior. When they are talking about that every movement matters. Because our patients don’t really know that, necessarily. At least, maybe I don’t think many of them know that every movement counts.
Every time you climb the stairs at your home to the second floor it matters. Then these five minutes three times per day is really a good thing and it is not a little thing! It is a good thing what you do for yourself and that is this really quite an effective behavior change technique to see to it that the patient also comes to that same level. Where they realize that yes it’s a good thing.
I cannot go to the gym for one hour. There is no way that I can put it in my in my daily life but I can do five minutes there and five there and five there. The importance of this is that it also heightens their own self-efficacy in handling their life situation.
27:43 Dr. Ginger Garner: Yeah, yeah especially when I will fully admit to them, as well as a therapist it’s what I do for a living, I don’t have a gym membership. I would not have time to go to the gym, if I had a gym membership. It’s also I think good for some people to hear sometimes that not every personality is suited particularly for a gym membership.
I heard Glennon Doyle say, she’s the author of Untamed, she wrote that she hates gyms because when she goes into a gym it’s just people shouting at her the whole time. Which feels really stressful and I totally can feel that. So you know if you’re a solitary exerciser or you like a walk in the woods, a walk in nature, five minutes here. Just like you said, five minutes there. The research overwhelmingly supports – it counts. It all counts. No you don’t have to have a gym membership to get fit, that’s for sure.
If you had one thing to recommend – one, two, or five things. Anne wrote our orthopedics chapter in Integrative and Lifestyle Medicine in Physical Therapy in the text that can be found at optp.com. Out of that orthopedics chapter, if you could pick a few clinical pearls to share what would be a few important things you’d want therapists to know.
29:13 Dr. Anne Soderlund: I would go and read the assessment methods and find my thing. Because PT’s also live in the working world, life is full of many things, and there is not much time to start and implement new things. Go there and find your thing. Ask that question or ask those two, three questions.
The second thing is about the treatment management part. There are two tables. One is on how to increase self efficacy. There are different ways to increase self efficacy and it is not so complicated, but if you are doing it systematically and really know what you are doing when you are showing the patients or group of people who are doing exercise in the group. When these people manage to do okay, these patients have a high self efficacy and you can see that in them.
The other table shows how to use behavior change techniques. These actually are normal things. Very many of those are normal things, what we are using. But we are not aware of when we are using these things. Feedback is an example or having an exercise diary. Then following up with discussing that with patients that there are so many simple things they can do. But being aware of what you are doing [as a physical therapist] when you are using these things makes it more effective.
Also because you should talk with the patients. The goals’ setting is moving. When we are setting goals together, it makes it easier for you to change your situation, your behavior.
So one assessment. Two or three assessment questions, or one. At least one! Then these two tables – one for self efficacy to increase in self efficacy and the other one and describing behavior change strategies.
31:56Dr. Ginger Garner: Thank you, thank you.
Dr. Anne Soderlund: I don’t remember the page numbers…but here okay I do. Page 220, no page 230.
32:05 Dr. Ginger Garner: Thank you, thank you. So make sure that you check those pages out. The orthopedic chapter does a lovely job of overview and these exact things that Anne has mentioned because without a systematic way of approaching it then it’s hard to change course. If we know we’re not documenting the techniques that we’re using and we’re not an approaching it in kind of a scaffolded way. So that chapter allows you to do that.
Let’s talk a bit to the general you know to everyone. To all of us who are trying to improve our lifestyle behaviors every single day. What do you think is one or two things that people should really know about integrative and lifestyle medicine, if you had to give them a few tips?
33:09 Dr. Anne Soderlund: The first one is actually and the one we were talking a little bit earlier is that every movement counts every every movement of your body counts for your health.
Think about that and let yourself get happy when you are just walking to the next station or bustop or whatever. Let yourself be happy that you are achieving something. Those are not little things. Also, it depends which kind of individual you are, but if you are an individual who likes to keep track of your doings. There are so many apps that help to motivate you through that well done, how about next time, can we meet tomorrow?
The app it is not anybody asking, but the app is asking can we meet tomorrow? And it is so motivating at least for me, but you need maybe a certain kind of person to use this kind of self monitoring.
34:35 Dr. Ginger Garner: Yeah, the the World Health Organization and the physical activity guidelines, have which the last update was in 2018 I believe, that assured us that there was no minimum for physical activity to make a difference and you know I wasn’t an app user and then I got an Apple watch for Christmas and I’m charging it yes I’m charging it now because it just died and I have actually enjoyed. I would have not gone and bought one myself, but I have really enjoyed the tracking that it does and the little you know glitter and fairy dust what not that it throws up in the air when you’ve, you know, you’ve met your physical activity. I do one from mindfulness for the day for yoga, for horseback riding , whatever it is that I’m doing.
So the mobile health apps really make a difference. I use those in my practice to monitor patients it’s to monitor all the lifestyle habits that we have. So yeah, no amount of physical activity is is too small and if you like that external motivation then check out and there are lots of free apps. You don’t have to buy an Apple watch but they are pretty fun. There are many many mobile apps that you can now you can reach out to see if you like them.
I’ve been asking this question to kind of to wrap up because I love music and so the question is what song do you think represents physical therapy from your point of view?
36:15 Dr. Anne Soderlund: Tina Turner – The Best. I think we are the best
36:22 Dr. Anne Soderlund: I think we are the whole song is about us. There are some parts that are really not matching.
36:49 Dr. Ginger Garner: I’ll have to look that one up. Right now all I can remember is “ simply the best…better than all the rest.”
Simply the best, we have not heard that song, I haven’t heard that song in a long time, I mean. I have to put that on my move, get my exercise playlist now.
Well thank you so much Dr. Soderlund. Thank you for being here, thanks for spending this time with me. Is there an easy way someone can get in touch with you? A website, or Instagram, or anything?
37:22Dr. Anne Soderlund: Yes, our website: www.mdu.se
38:00 Dr. Ginger Garner: Yeah, thank you so much. Have a lovely rest of your day and we hope to see you soon in the future
38:09 Dr. Anne Soderlund: Yeah, you too. Thank you for a nice discussion this was really fun!
38:15 Dr. Anne Soderlund: I hope to meet you in future, maybe
38:18 Dr. Ginger Garner: Oh, I hope so too. I hope so too.
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