The check book theory (of health) developed and taught by Tim McGonigle, PT, Folsom Physical Therapy
Just a couple of days ago, I chatted with a friend about her frustrations in working with a client who kept hurting their body through athletic pursuits. She sighed “I get this person to the point where they are feeling pretty good, and then they go out and go off jumps on their bike* and come back to me in a heap”.
I nodded on the other end of the line (super unhelpful when you’re on the phone it turns out), in empathetic frustration, reflecting on similar clinical cases.
A couple of years ago, I was working with a client who was recovering from a spinal surgery. We were stumbling through his rehabilitation- every time we met, we would discuss the phase of healing he was presently in, activities/ behaviors to modify and I would progress him through therapeutic exercises and hands on work to restore his soft tissue mobility and promote fluid exchange. The clients’ biggest challenge was his behavior modification. He had such a tough time accepting the phase of healing he was in and his limitations, that he kept challenging them. Each meeting, he would share an illicit activity: helping a friend move furniture, taking a long mountain bike ride on single track trails, trying out running. On and on.
I spoke with my mentors about his case and my concerns with his self-harming actions during mentoring sessions via emails, and on more than one occasion. We hatched a plan around providing education and information to help him with behavior modification. Barring success in these interventions, they encouraged me to reconsider working with the client- to refer him back to his doc, to refer him to a different PT, if I couldn’t get him on board with modifying his behavior. Through the lens of their expertise, the writing was on the wall that this person was going to “fail” rehab.
The day of our last meeting was a long one. I was having a strange week, and I met with him at my last appointment of a long day. He limped into my office, in much worse shape than when I had seen him last. He explained that over the previous weekend he had gone to an indoor trampoline center, done flips and had fallen off the trampoline, onto the floor- contacting the hard surface with his freshly operated spine*.
(Events have been slightly modified to protect identities).
I felt hot anger pulse through me like a fever. I felt fearful for the injury this person had subjected themselves to- for seemingly no reason. I felt angry about all of the resources spent: all of the money, time and work on his back- from the surgery on through to the rehabilitation, was potentially gone in an instant.
The hours of conversations and work to support his healing had been effectively wiped out in one impulsive action. I quickly realized, in that second, my important and yet limited role in the rehabilitative process.
Until a client is able to know that they are at least half responsible for their wellness, any attempts at healing are extremely limited. Not only does a client or patient need to meet the provider at the 50 yard line in order to ensure their successful progress, they need to see deeply into their own processes that affect their outcomes.
People may buck this notion- immediately they may feel a sense of abandonment at the practitioner not doing the healing for them. But ultimately, participation allows for a greater sense of autonomy and owning of physical outcomes for clients. And it is real. It is not real or true to expect that someone else can ever grant you health.
Tim McGonigle teaches this concept so clearly in his “checkbook” theory of orthopedic management. In the checkbook theory, as with a bank account, you and the client work to identify all of the conditions that promote healing to a musculoskeletal issue. This may be anything that contributes to global or local conditions (which I can get into next session): everything from the forces you introduce to your muscle and ligament to your general health and integrity of your central processing.
Activities that promote “deposits” and “withdraws” will be unique to the injury or illness and the individual. If you are uncertain what these might be and would like to explore these concepts, please ask your physical therapist.
Some activities that might promote “deposits” into an account:
appropriate exercises for the phase of healing you are in
an ice pack with elevation
education and insight
Some activities that might “withdraw” from your checking account:
exercise that is at an inappropriate level for your phase of healing
hands on work that it not at the right level to promote healing
too much rest
belief that your health is out of your own hands, and the provider will cure you*
It is important to note that the checkbook theory requires and promotes management and challenges the notion that musculoskeletal issues can have a “full resolution”. Just like with our own checking accounts, there is not a time when we can spend endlessly without overdrawing our accounts. Our bodies are not something that we can fully resolve and keep on autopilot (maybe like we did when we were 17). As we age, in the presence of disease, following orthopedic surgeries, we become care takers of our physical accounts.
Some of us may start with accounts with $10,000 in them. Some of us may be starting with accounts at -$80,000 and still be in pain/dysfunction despite a round of positive intervention leveling us up to -$50,000.
In using the checkbook theory with my acrobatically inclined client, I can see that we had painstakingly been carving out a surplus during our rehabilitative sessions, that he was quickly spending (and then some) as soon as he left the clinic. Without his behavior modification, there was no way to make the rehab work- he was in a constant deficit.
That experience was such a lesson for me in drawing boundaries around what I will accept in client behavior and also the limits of my own work as a physical therapist. The specifics are not at all important.
What is important is that the provider and the client see a couple of things from this model:
1) Orthopedic and musculoskeletal issues (just like an issue in any other system) are to be managed rather than fully resolved
2) Clients meet their providers in their responsibility for care. Providers may initially help a client understand what creates “deposits” into their accounts- but it is always and only up to the clients to follow through on those deposits
3) Wherever we currently are on the scale of our account (withdrawn or overabundance) we can all make the changes we want through changes in our behavior, education and understanding. Stay the course with what works and remain as patient as possible. Our degenerative issues have often taken us 40+ years of withdrawals (!) You cannot expect to have a positive account after 2 months of positive change.
Are you a client constantly overdrawing your account? If you are interested in smoothing out and maximizing your recovery and function:
1) Speak with your provider to clearly assess withdrawal vs. deposit behaviors
2) Examine your own willingness to make changes in your beliefs and behaviors
3) Take stock of where you are: you can speak with your trusted doctor or behavioral health provider about challenges you are having accepting aging, accepting medical diagnoses, understanding illness or pathologies you may be working with and how they may impact your function
4) Make note of where you have already had success making change. You may have: improved your gum health after developing a flossing habit or lowered your cholesterol after reducing animal fats in your diet. Note your previous “wins” to help you rally around your own capacity to make lasting physical change
Happy Moving! (and teaching)