Modified Mondays: “Risk” and why are PTs ok with it?

In February, I injured my shoulder and ended up with a possible rotator cuff tear. I ended up in physical therapy for some stability training and strengthening. Since then, I have been struck nearly every session by how comfortable with risk the PTs seem to be. Now. I’m not going to get cliché and talk about how every PT I know has had a little bit of sadistic tendencies, but let me just tell you I cried in therapy once and basically the therapist was pretty happy about it. During a session a couple weeks ago, the PT had me working with a barbell on some deadlifting and rows. It felt pretty good, so he had me try an overhead lift with a little weight on the bar. It did NOT go well, my shoulder was definitely not ready and there may have been crying again. He shrugged and said, “Well-it was good to try it. Worth the risk to see if you were ready.” He could be risking pain, risking increased injury, even risking a more severe tear that could result in surgery… and still saw the value in the risk.

In swallowing, SLPs don’t seem to have the same approach to risk. We view it as something to be eliminated completely, even if it means that the patient is potentially kept from making progress towards a diet they want. If the patient WANTS to take the risk, we call them “noncompliant” and even suggest they discharge from therapy. If they drink something they aren’t supposed to, we call it “stealing” or “sneaking”. (Compare this to my confession to my PT last week that I went kayaking, even thought he told me it wasn’t a good idea-and instead of noting my “noncompliance”, he just asked me how it went and how I felt about it.) We do this with good intentions, thinking we are keeping them from getting pneumonia, but we have good evidence that shows pneumonia development in dysphagia is not as risky as we thought once upon a time.

For more thought on risk: This patient is a great example of how avoiding “risk” can actually have it’s own set of consequences. He was made NPO while in acute care without instrumental due to “risk of aspiration”, got a PEG, and then was discharged to a skilled nursing facility, and was kept NPO due to the same “risk”. In the SNF, the patient developed an infection at the PEG site, and ended up back in the hospital, where they pulled the PEG and dropped an ng “until infection managed” and still no instrumental. When the patient returned to the SNF, our team was called in to complete the MBS, which showed a quite lovely and functional swallow. We obviously can’t know what the patient’s swallow looked like at the time of the original NPO recommendation…. but the point being that by attempting to avoid the risk of aspiration, the patient was put at risk for infection and the consequences (including a readmission) of that infection.

Finally, risk is something that dysphagia clinicians have to be aware of, and balance out with all the other aspects of patient care. Dysphagia management doesn’t happen in isolation… and sometimes risk is worth the progress that can come from it. Except when my PT makes me cry by risking pain, that is just plain mean.