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Why I don't like the 'toolbox' concept

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  • Tip Why I don't like the 'toolbox' concept

    I have never liked the toolbox approach to any process - and this includes physical therapy. A toolbox is full of products without an underlying process - and that does not lead to a defensible and consistent approach that handles complexity well. More on process vs product here: Manual therapy: process or product? To me, a toolbox or 'eclectic' concept is a disorganized approach centered around applying different tools or products without a consistent reasoning process or thinking model behind them. Having tools in your box doesn’t tell you when and how to use them and toward what goal. Toolbox approaches are about the practitioner not the client or patient. For these toolbox clinicians, they tend to use their favorite tools first then fall back on a somewhat random series of other tools if they don't get the response they need. Tools themselves won’t get you anywhere, what matters is the reasoning process that underpins it all. I'm not against using different modalities or approaches, I'm against using them without a consistent reasoning process.

    I encourage people to dump their toolbox out and focus on learning processes of care and training that allow you to:work toward different goals, that you can use with a variety of patient/clients, which allows you to integrate new information, and be consistent with published evidence. I have seen very, very few people with multiple modalities of care who could provide them with a defensible reasoning process - especially since so many tools are inconsistent with each other. For example, if STSI (scraping the skin with instruments) was a sensible approach, why would needling make any sense?

    When I hear someone say something like 'wow this is a great thing to add to my toolbox!' I just cringe. Maybe now you will too.

    See attached some photos of a 'clinical toolbox' my colleagues got me as a going away present once. Note the little Bosu ball!!
    Attached Files
    Jason Silvernail DPT, DSc, FAAOMPT
    Board-Certified in Orthopedic Physical Therapy
    Fellowship-Trained in Orthopedic Manual Therapy

    Certified Strength and Conditioning Specialist

    The views expressed in this entry are those of the author alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

  • #2
    Without a carpenter that knows the process, a bigger toolbox is just a big waist of money. I can spend lots of money at Lowe's getting the latest and greatest tools marketing can sell me, but I will suck at carpentry unless I understand the processes behind it all.

    Great post Jason.

    sent from my phone using tapatalk, mistakes possible
    Kory Zimney, PT, DPT

    "Study principles not methods, a mind that can grasp principles will create its own methods." - Gill

    "All truths are easy to understand once they are discovered; the point is to discover them." - Galileo Galilei


    • #3
      Well, I am not going to lie. Feel like I have been kicked in the groin. So much to learn.


      • #4
        Well, I have always wondered what a toolbox consists of.

        The US gel I recall from ?10-12 years ago, before we put all machines in mothballs. The foam thing took off after I left work -and the rest? Elements of what happens when one searches for new things to use instead of new ideas and thoughts?
        The roll of foam works like magic in the pool when a kid is learning to swim. Probably best left there?


        • #5
          There's always more to learn, don't worry about feeling like the wind has been taken from your sails - that happens a lot around here!

          I agree with you about the toolbox concept - to me it almost looks like you rummage around trying to find the "best thing" rather than carefully selecting a strategy, testing it, then refining it as you review the outcomes.
          But at the same time, it's better than having only one tool (a hammer) and seeing only nails...
          It is the mark of an educated mind to be able to entertain a thought without accepting it. ~Aristotle


          • #6

            For a carpenter, having a hammer is useful because the nail actually exists.

            True to the adage "the cart before the horse", therapists have invented nails so they can use their proverbial hammer.


            • #7
              I agree with Mikal, we have brought some inappropriate tools along.
              You don't see hairdressers use hammers or compasses.


              • #8
                Thanks Jason - I share your dislike of the word in our profession.
                Imagine an electrician adding a sledge hammer, hammer drill and ripsaw to his toolbox.
                Or a neurosurgeon adding a tile saw and jackhammer.

                When I hear about "adding to the toolbox", fist thing that comes to mind is: "But WHAT are you going to actually treat with it?"
                We don't see things as they are, we see things as WE are - Anais Nin

                I suppose it's easier to believe something than it is to understand it.
                Cmdr. Chris Hadfield on rise of poor / pseudo science

                Pain is a conscious correlate of the implicit perception of threat to body tissue - Lorimer Moseley

                We don't need a body to feel a body. Ronald Melzack


                • #9
                  I'm against using them without a consistent reasoning process
                  Hmmm, I agree. If there is anything lacking in physiotherapy it is the capacity to reason through a meaningful, logical process.

                  While treatment paradigms such as MDT and Maitland provide such a framework they both fall within a wider context of working from a bio-(mech)medical understanding of the body or treatment effects upon it. WHile some of that can be addressed by widening the conceptual framework into a BPS model this again remains limited as it is often taken to refer to the treatment encounter - effectively it risks becoming another toolbox with similar kinds, if different types, of tools.

                  Do we need a more robust exploration of how we are thinking about the process of treatment of an individual encapsulating a much broader theoretical framework that addresses how we reason - i.e. it contains some understanding of the philosophy of both the patient and clinician - a metaphysics of physiotherapy? My concern would be that unless we alter what we mean by assessment we will almost inevitably be driven to adopt a tool based approach.


                  ANdy (aware he has probably failed to articulate his point )
                  Last edited by amacs; 09-02-2015, 09:38 PM.
                  "Here is Edward Bear coming downstairs now, bump, bump, bump, on the back of his head behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there is another way, if only he could stop bumping for a moment and think of it." A.A. Milne


                  • #10
                    I agree that a toolbox approach suggests (quite strongly) the 100% operator-based action. There could be an argument that using tools is impressive to the patient (placebo response) and allows for interaction while the tool is being used - but it is not quite the same as allowing the patient to voice whatever emotions are bugging him or her, and for the PT to listen, usefully.

                    It also suggests, to me, a Cartesian approach to pain. Not good.....


                    • #11
                      Catching redfish on the Texas Gulf Coast with a flyrod is challenging. It's also frustrating. So many factors go into whether or not you'll come away from a trip with a great catch (and/or release) or get completely skunked.

                      There are so many variables involved. Most of them are completely out of the hands of the angler. The few that are rely on attention, awareness, and persistence. A committment to practice and study of the environment and behavior help a lot.

                      Some elect to catch their fish with reasonably priced tackle (rods/reels etc.) and others like to sport the most expenisve stuff on the water. At the end of the day, the tools make very little difference.

                      Like Jason, I cringe when someone says "it's another tool". More often than not, "it" is a crutch. A desperate grasp at something, anything to make up for their lack of understanding coupled with a pathologic desire to please.
                      Rod Henderson, PT, ScD, OCS
                      It is useless to attempt to reason a man out of a thing he was never reasoned into. — Jonathan Swift


                      • #12
                        Great analogy Rod.

                        Now why do you go fishing ?
                        "Here is Edward Bear coming downstairs now, bump, bump, bump, on the back of his head behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there is another way, if only he could stop bumping for a moment and think of it." A.A. Milne


                        • #13
                          I used some of your stuff on my TMJ patients.

                          Said to me many, many times by former students.
                          I've never actually done a spit take while hearing this but that was probably because I wasn't drinking anything at the time. More likely, I tried hard not to express my despair. This hasn't always worked out.

                          Put "toolbox" in the search function of this site and you'll come across five pages of threads, including this one containing an excellent bit of advice from Jason in post #50.

                          The thread was written in '06.
                          Barrett L. Dorko


                          • #14
                            Originally posted by amacs View Post
                            Great analogy Rod.

                            Now why do you go fishing ?

                            It can't be just because your name is "Rod"...
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                            • #15
                              Could NOT agree more... The term 'tool box' is almost as bad and meaningless as when I hear many therapists use the term 'adjunct'.

                              EBP for some = excuse based practice
                              Attached Files
                              Adam Meakins
                              Do not mock a pain you have not endured