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This is to certify that the
dissertation entitled
PHYSICAL THERAPY AS COMMUNICATION:
MICROANALYSIS OF TREATMENT SITUATIONS

presented by

Kerstin Margareta Ek

has been accepted towards fulfillment l
of the requirements for

Ph. D. Education

degree in

 

 

 

Major professor

Date Sept. 20, 1990

 

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PHYSICAL THERAPY AS COMMUNICATION:
MICROANALYSIS OF TREATMENT SITUATIONS

BY

Kerstin Margareta Ek

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Department of Teacher Education

1990

_ r70 4

n,

«9

ABSTRACT

PHYSICAL THERAPY AS COMMUNICATION:
MICROANALYSIS OF TREATMENT SITUATIONS

BY
Kerstin Margareta Ek

A microethnographic case study was carried out to
learn about how patients and physical therapists interact.
A patient with a "frozen shoulder" was followed through
treatments at an outpatient clinic. Data collection
included participant observation, videorecordings of
treatments, viewing sessions with participants, and
interviews. Videorecorded material was analyzed to answer
the questions "What do a patient and a therapist do and say
during treatment? How do they talk with one another? What
psychological and pedagogical aspects can be inferred from
a content analysis of their talk and actions?"

Phases of "hands-on" and "hands-off" alternated as a
"treatment dialogue" was interwoven with "conversations."
"Treatment dialogue" consisted of the therapist's verbal
and physical instructions and feedback and the patient's
inaudible physical responses and vocal comments.
"Conversations" were primarily initiated by the patient.
With the two dialogues happening simultaneously, the use of
different styles of talk, and of different interpretations
of what was going on, accounts were given for why moments

of confusion occurred in spite of the patient and therapist

 

Kerstin Margareta Ek
being familiar with one another and the treatment routine.

Patient’s talk about her dilemma, was interpreted by
me to be important for recovery. Her talk turned the
therapist into a listener, and therapy into the act of
listening.

Aspects of teaching and learning were explored.
Instances of non-learning illuminated the different
perspectives the patient and therapist reasoned from.

This study questions the relationship between a
patient and a therapist, what is therapeutic about
treatments, and how knowledge is gained. It argues that
treatment situations need to be conceptualized as jointly
co-produced by the patient and therapist moment by moment

in real time, and as occasions where knowledge is created.

ACKNOWLEDGMENTS

Many people have been helpful during the course of
this study. The members on my dissertation committee, Drs.
Charles Blackman, Doug Campbell, Frederick Erickson, and
Susan Florio-Ruane have, at different points in time and in
different ways, provided professional advice as well as
personal support. This is deeply appreciated and will
always be remembered.

My friend and colleague Gunn Engelsrud I thank for the
interest she has shown, for the challenging discussions we
have had, and for her friendship. Raija Tyni-Lenne and Lena
Nilsson-Wikmar, my colleagues at the Department of Physical
Therapy Education, Karolinska Institute, Stockholm provided
support at critical moments.

My friends Gun Steneroth, Kerstin and Jan Nordstrom,
Kim and Joe Andrejzcuk, my brother Mats Ek and his family,
I thank for their trust, encouragement, and hospitality.

My mother, Marta Pettersson, has been significant to
my work in her listening, in questioning, in never losing
her dignity in spite of serious illness. My daughter,
Gabriella, has been just as important. I thank her for

reading parts of the manuscript and commenting upon it, for

iv

telling me when it was time to finish, and for bearing with
me.

Finally, I offer words of appreciation to the patient
and the physical therapist of this study, who enabled me to
learn about research, to discover essential features of
therapeutic encounters, and to begin to understand the

dynamics of face to face interaction.

All my knowledge of the world, even my scientific
knowledge, is gained from my own particular point
of view, or from some experience of the world
without which the symbols would be meaningless.
The whole universe of science is built upon the
world as directly experienced, and if we want to
subject science itself to a rigorous scrutiny and
arrive at a precise assessment of its meaning and
scope, we must begin by reawakening the basic
experience of the world of which science is the
second order expression. Science has not and will
not have, by its nature, the same significance
qua form of being as the world we perceive, for
the simple reason that it is a rationale or
explanation of that world. (Merleau-Ponty, 1962,
p. viii)

vi

TABLE OF CONTENTS

List of Tables
List of Figures

List of Appendices

EEQIIQN_I= INIELLEQIHAL_BQQI§_QE_IHE_§IHDX

CHAPTER ONE: THEORETICAL FRAMEWORK

Assumptions about Physical Therapy
Views of Physical Therapy
Definition of Experience and Reflection
Concepts of Communication
Shared Communicative Competence
Context Analysis
Contextualization Cues
Conversation Analysis
Communication as an Overriding
Principle in the Study of Physical
Therapy Practice
The Purpose of the Study
The Organization of the Thesis

CHAPTER TWO: REVIEW OF THE LITERATURE

Part I: Overview of the Physical
Therapy Profession

Background of the Physical Therapy
Profession
Models of Physical Therapy Practice
The Hislop Model of Pathokinesiology
The Psychobiological Adaptation Model
The Physiotherapy Model
Similarities and Differences between the
Psychobiological Adaptation Model and

vii

Page
xi
xii

xiii

[.0

P'Htfl
osmcooamcnuiw

17
19
21

23

24

24
30
30
32
33

the Physiotherapy Model 33

The Need for Empirical Studies 35
Psychosocial Aspects of Physical Therapy
Practice 37
Communication as a Treatment Technique 44
An Existentialist View of Physical Therapy 46
Summary 47
Part II: The Shoulder Joint 52
The Architecture of a Joint 52
The Scapulohumeral Joint 53
The Movements of the Arm 54
Classification of Movements 56
The Muscles 56
Function of Muscles 57
Part III: The Diagnosis of Frozen Shoulder 58
Symptoms of the Idiopathic Frozen Shoulder 60
What Causes a Shoulder to lose its
Mobility? 61
Personlity Studies 63
What is the Most Effective Treatment? 65
What is the Effect of Physical Therapy
Treatment? 66
Summary 69

CHAPTER THREE: THE STUDY: ITS QUESTIONS AND

METHODS 72
Questions of the Study 72
Justification for the Study 73
Restatement of Purpose 74
Original Research Questions 75
Research Questions that Emerged During
the Study and During Analysis 77
Methods of the Study 80
Choice of Physical Therapist 82
Choice of Setting 83
Choice of Patient 84
Data Collection Procedures 84
Categories of Patients 88
The Patient in the Study 91
The Physical Therapist in the Study 94
The Medical Center 95
The Physical Therapy Setting 96
The Purpose of Videorecording Treatment
Sessions 98
How the Videotapes Were Made 102
Viewing Sessions with the Participants 106

viii

Phenomenological Approach to Data

Analysis 108
Analytic Viewings of the Tapes 110
Transcriptions 114
Analysis of the Transcriptions 120
Videotapes Selected for Detailed

Analysis 122

Issues of Trustworthiness 125
Summary 129
EEQIIQN_II= DE§QBIEIIQN_AND_ANALX§I§_QE
THE_EINDIN§§
CHAPTER FOUR: DOINGS AND TALK DURING MANUAL
TREATMENT 1 3 1
Part I: The Doings of the Patient and
the Therapist 131
Phases of Stretching ("Hands-On") and
Phases of Recovery ("Hands-Off") 133
Stretching as a Therapeutic Technique 137
The Critical Moment During the Stretch 142
Characteristics of a Hands-On Phase 145
Characteristics of a Hands-Off Phase 145
How a Session Comes to be Organized
Around a Specific Treatment 146
Part II: Talk During Manual Treatment 150
Time of Talk and Silence 151
Categorization of Styles of Talk 154
Therapist Talk: Its Styles and Functions 159
The Form of the Therapist's Talk 165
Patient Talk: Its Style and Form 169
What Does the Patient say About her
Shoulder? 170
Conclusions about Therapist Talk and
Patient Talk 173
The Theme Brought up most Frequently
by the Patient 177
Different Interpretations of What is
Going on 186
Summary ‘ 190
CHAPTER FIVE: EPISODES OF CONFUSION 193
How Participants Arrive at Endings and
Beginnings of Hands-On Phases 193
How Episodes Have Been Selected 197

ix

Criteria for Inclusion 199

Description and Analysis of the Episodes 201
Episode 5:1/Analysis E 5:1 201
Episode 6:1/Analysis E 6:1 205
Episode 6:2/Analysis E 6:2 211
Episode 7:1/Analysis E 7:1 215
Episode 7:2/Analysis E 7:2 219
Episode 7:3/Analysis E 7:3 222

Summary 224

CHAPTER SIX: PHYSICAL THERAPY SESSIONS AS

EDUCATIONAL EVENTS 230
Psychological Aspects of Physical Therapy
Sessions 232
Aspects of Teaching and Learning in the
Physical Therapy Session 236
What the Therapist Needs to Learn
and Wants to Teach 240
What the Patient Wants to Learn
and Tries to Teach 241
Summary of Teaching and Learning Aspects
of the Physical Therapy Session 246
Instances of Non-Learning 247
Questioning the Goals of Physical Therapy 253

EEQIIQN_III: QQNQLQEIQNE

CHAPTER SEVEN: CONCLUSIONS AND IMPLICATIONS FOR
THERAPY, RESEARCH AND EDUCATION 255

Summary of Findings 256
Issues Illuminated in This Study 263

A Second Analysis of the Physical
Therapy Literature 270
Implications for Therapy 274
Implications for Research 278
Implications for Education 281
Epilogue 285
REFERENCES 287
APPENDICES 296

Table

LIST OF TABLES

Appointment Times and Mode of
Recording

Date for Viewing Sessions, Videotape
Being Analyzed, and Participant

Distribution of the Number of Turns
Occurring in all Hands-Off and Hands-
On Phases

Distribution of the Number of
Functional Units Occurring in all
Hands-Off and Hands-On Phases

Categories of Styles of Therapist Talk
and Patient Talk

Locations of the Utterances by the
Patient Regarding the Present
Condition of her Shoulder and the

Page

87

88

152

152

156

Therapist’s Responses 180-182

Estimated Amounts of Comments by the
Patient and the Therapist that are
of Positive or Negative Character

Distribution of who Takes the
Initiative to Start a Hands-On
Phase and the Type of Initiative

Overview of Episodes of Confusion.
Identification of who Displays
Readiness to Work and the Issue of
Disagreement that Contributes to the
Confusion

xi

189

196

199

 

Figure

3.1

LIST OF FIGURES

Treatment Area, Physical Therapy
Unit

Distribution and Duration of all
Phases During Manual Treatment
5/3/84 (Video X)

Style of Talk and Type of Activity and
Their Occurrencies. Locations of
Episodes of Confusion According
to Phase

Working Position, External Rotation
(Video X, Hands-on III, 5/3/84)

Working Position, Forward Flexion
(Video X, Hands-on I, 5/3/84)

xii

Page

97

135

158

209

209

APPENDICES

Appendix
A Date and Number of "Steps on
Ladder"

B Physical Therapist Consent Form
C Physical Therapist Consent Form
for Video and Audiotaping

D Patient Consent Form for
Observation and/or Video and
Audiotaping

E _Amount of Phases and Stretchings
per Hands-on Phase on Three
Different Occasions

F Transcript: Hands-on VI
(Forward Flexion)

G Transcript: E 6:1

H Transcript: Transition
Hands-on V/Hands-off VI

I Date and Measurement of Shoulder

Mobility in Degrees

xiii

Page

296

297

299

301

303

304

306

309

310

SECTION I

INTELLECTUAL ROOTS OF THE STUDY

CHAPTER ONE

THEORETICAL FRAMEWORK

Qualitative research has its philosophical roots in
phenomenology (Merriam, 1988). This micro-ethnographic case
study of physical therapy sessions is guided by existential
phenomenology, which serves both as a theoretical
foundation and as a mode of inquiry. It takes the living
world of the patient and the physical therapist, as it is
expressed in treatment situations, as a point of departure.

The philosophical concepts of "being-in-the-world," of
"experience," and of "reflection" are thought about as
being firmly rooted in any situation and as phenomena that
can be studied. In other words, the emphasis upon physical,
bodily matters in treatment situations lends itself to
examination of what bodily experiences there are: how they
are expressed: and how a treatment situation turns into a
different experience for the patient and for the therapist.

Physical therapy treatment is not something that is
part of the everyday life of people. It occurs mostly when
an injury or a disease has done some damage to one’s body
and a "restoration" is required. For a physical therapist,

treatment situations constitute her working day. There is

2
ground to assume that treatment situations are approached
differently by the patient and by the therapist.

The reason for the patient’s and the therapist's being
together, the physical trauma the patient suffers from and
the treatment modality the therapist offers, are central
for understanding what is talked about, perceived, and

acted upon during the session.
Assumptions about Physical Therapy

The following assumptions are held regarding physical
therapy. The therapy involves longterm and repeated contact
between a therapist and a patient: in the course of
treatment physical contact is often needed with the
therapist’s "laying on of hands" being very much part of
her work: the living body and movements are in focus when
delivering physical therapy. During treatment the patient
and the therapist are present to each other moment by
moment and they take account of each other's actions. Both
of them are acting and reflecting human beings. Both of
them have intentions and knowledge, although of different
kinds. Both of them teach and learn.

This study approaches teaching and learning from a
social constructivist's perspective and assumes that
knowledge can be inferred in the doings and the talk of the

patient and the therapist. The assumptions also encompass

3
the idea that the patient’s knowledge and the therapist's
knowledge are of little value when isolated from each
other, but when they intermingle during the course of
treatment they are of the utmost importance in leading to

the creation of new knowledge.
Views of Physical Therapy

In a traditional view of physical therapy, the
therapist is considered the teacher and the patient the
learner. The therapist is educated to "help restore motion
homeostasis" (Hislop, 1975). The patient is the person
whose mobility has been impaired. This implies an
asymmetrical relation, if we look at the distribution of
specialized knowledge. It is the therapist who determines
what treatment should be carried out, what movement a
patient should practice, when to introduce, for instance,
strengthening exercises. All that is required of the
patient is to do as instructed, to comply.

Such a description can easily be translated into a
context or a relationship of already set rules. If a
treatment situation were perceived by both participants in
this way and accepted as such, there would be no need for
negotiations to occur, for discussions to arise, for
difficulties to appear and be resolved. But a therapy

situation may be viewed in other ways by the participants.

4
For example, it can be viewed as a service-like encounter
where the therapist is expected to serve the patient’s
needs. Alternately, it may be viewed as a teaching/learning
encounter where both the patient and the therapist have
something to learn and something to teach. What will be
taught and learned will also change over time. It may also
be viewed as an encounter in which bodily knowledge,
reformulated and expressed in words, both by the patient
and the therapist, alters or enriches one's understanding
of a particular physical condition.

This study refutes the notion of a "causal
relationship" or causal linkage between a health
professional and a patient or between therapeutic
interventions and patient outcomes (Jensen, Shepard, &
Hack, 1990) which is implicit in many specialized/
professional service organizations. But this does not mean
we lack ideas about how the encounter is or could be
construed. Being a naturalistic study it assumes that "All
entities are in a state of mutual simultaneous shaping, so
that it is impossible to distinguish causes from effects"
(Lincoln & Guba, 1985, p. 38).

One means of thinking about physical therapy sessions
is to adopt a social constructivist’s perspective. This
influences one's view of treatment situations and
encourages application of the concept of communication to

their study. Philosophers and social scientists holding a

5
social constructivist view stress how human beings are
actively creating their own worlds, their own realities.
They stress the continous effort we engage in to make sense
of what is happening around us, of our attempts to
understand.

One research tradition that builds upon these
philosophical assumptions is ethnography and particularly
constitutive ethnography. The premise of constitutive
ethnography is that "social structures are interactional
accomplishments which are mutually constructed by the
participants in them" (McCollum, 1989, p. 136). Within this
framework, treatment situations are seen as being socially

organized by the patient and the therapist.

Definition of Experience and Reflection

One of the intentions of this study is to illuminate a
patient’s and a therapist's concrete experience of
treatment situations as being potentially physico-
therapeutic, psychotherapeutic, and pedagogical teaching
and learning encounters, and that this is expressed by the
participants during the session itself. To begin that task,
it is useful to define "experience" in a way that guides
the study’s questions and methods as well as its

theorizing.

6
Schutz' definition of experience is explained by

Wagner (1970) in the following way:

The basic starting point of all phenomenological
considerations is the essential actual, or

immediatel¥__ixid experience. that is. the
subjective, spontaneously flowing st ream 2f

exp_;igpgg in which the individual lives and
which, as a stream of consciousness, carries with
it spontaneous linkages, memory traces, etc., of
other, prior, experiences. Experience becomes
only by an act

of reflection in which an essentially actual
experience, in retrospect, is consciously
apprehended and cognitively constituted. In the
course of his life, a person compiles a stggk_gf

e ° , which enables him to define the
situations in which he finds himself and to guide
his conduct in them. (p. 318: emphasis in
original)

Langer (1989) interprets existential philosophy in the

following way:

... for an understanding of our being-in-the-
world, existentialist philosophy seeks to awaken
us to an awareness of our fundamental involvement
in a natural-cultural-historical milieu. It
stresses that we are not neutral observers but
rather, situated participants in an ongoing,
open-ended, socio-historical drama. It claims
that truth comes into being in our concrete co-
existence with others and cannot be severed from
language and history. The existentialists declare
that a non-situated human being is inconceivable.

(p- iV)

Merleau-Ponty (1962), influenced by Husserl, stresses
that it is through perception we are able to experience the

world. He argues that the perceiver is not a pure thinker,

7
but a body-subject and that "intentionality of
consciousness is first and foremost a bodily
intentionality” (Langer, 1989, p. xiv). The subject, to
Merleau-Ponty, is the living body, and consciousness is
defined as an "active meaning-giving operation" (Merleau-
Ponty, 1961, p. xi). He says "Because we are in the world,
we are condemned to meaning, and we cannot do or say
anything without its acquiring a name in history" (1961, p.
xiv).

In physical therapy, the focus is upon the body and
its movements. By adding the word "living," so we get the
"living body," we can remind ourselves, again, that the
people we see, the patients, are not only bodies composed
of parts. By thinking of them as being just as involved in
the ongoing situation, the ongoing treatment, as we
ourselves are, we can begin to appreciate how both of us
shape the situation at hand. By reflecting consciously upon
what happens in treatment situations, we can begin to
understand who the patient and the therapist become during
that particular encounter.

The application of certain concepts from the field of
communication to treatment situations is one way of
illuminating how the participants themselves define and
shape each session. However a treatment turns out, it is
accomplished in interaction. In communicative terms there

is no longer a difference between the patient and the

8
therapist, since both possess interactional competence.
This is based on communicative knowledge that is
"institutionalized" as well as "emergent," to use

Erickson’s terms (1986a).

Concepts of Communication

When thinking about a patient and a therapist as
interacting successfully in face to face situations, one
fundamental issue to stress is the communicative competence

they share.

Shared Communicative Competence
Institutionalized knowledge is the ability to use

linguistically proper ways of speaking, such as correct
syntax and lexicon. Also taken for granted are "culturally
learned patterns for the use of speech" (Erickson, 1986a,
p. 295). These are, among other things, to know how to
speak appropriately in different situations: what patterns
of sequencing to expect in ordinary activities: to know and
be able to apply principles that organize discourse, for
example, an answer follows a question. Institutionalized
communicative knowledge represents "general systems of
rules or operating principles for the conduct of talk"
(Erickson, 1986a, p. 296). Emergent communicative knowledge

is another dimension:

9
It is the domain of praxis in reasoning, the
capacity to create sense in addition to following
rules, to go beyond what is culturally learned
and, in the midst of the fortuitous contingency

of the moment, to play interaction by ear. (p.
296)

Communication in a general sense can be defined in a
variety of ways and it can be studied from different
perspectives. Some consider all behavior to be
communicative in nature (Ruesch & Bateson, 1951), others
that behavior is only considered "communicative" if the
person providing it intends to convey some message,
regardless of whether anyone else receives the message
(Ekman & Friesen, 1981). This last proposition is
challenged by Kendon (1981) who argues "The question of
intentionality is irrelevant because ... to witness a
behavioral event is to receive information" (p. 9).

When looking at how those different conceptions of
communication relate to the basic components of
communication--the sender, the message, and the receiver--
one finds that they are based on different assumptions
regarding responsibility for whether something has been
communicated or not. For example, Ruesch and Bateson, and
Kendon, assume that the "burden" of communication lies on
the receiver, while Ekman and Friesen place it upon the
sender. Depending on what researchers tend to focus upon,

be it the relationship between the sender and the message

10
or the receiver and the message, different properties of
communication come to be accentuated.

Central to constitutive ethnography is the study of
speech. Forms of speech and prosody, and their relevance
for participants, all merit attention. It is equally
important to incorporate how speakers and listeners
gesture, alter their facial expressions, and orient
themselves toward each other in face to face encounters in
order better to understand how interaction is accomplished.
About the significance of interpretation of speech,
prosody, and gesture in conversation, Paget (1983) has

written:

Talk, when it is serious rather than casual, is
as much as is anything at all a labor of
understanding, of listening and interpreting, of
clarifying and acknowledging what has been said,
and responding. It is an interactionally
constituted activity sustained by
conversationalists. (p. 72)

The multimodal nature of communication assists, through its
redundancy across verbal and non-verbal channels, the

interpretive work of participants.

W

One group of researchers claim that one cannot
separate the three entities--the sender, the message, and

the receiver--from each other if one is to learn about the

11
collaborative work participants employ. They study the
relationship between all three using audio-visual records
(Erickson & Shultz, 1982: Florio, 1978: Kendon, 1981:
McDermott, 1976: Shultz, Florio, & Erickson, 1982). While
the speaker is saying something, the listener (receiver)
reacts to what is being said, affecting both the speaker
and the message. This dialectical way of thinking about
communication is radically different from focusing upon
either the sending end or the receiving end of the
continuum, because it places the "burden" of communication
as much on the receiver as it does on the sender and the
message itself. McDermott (1976) is particularly concerned
with "how people establish environments for each other and
for themselves, and how these environments constrain their
next activities" (p. 28).

This group of researchers follows an approach called
context analysis (or "microethnography" or "constitutive
ethnography"), which originated in the work of Ruesch and
Bateson (1951), Birdwhistell (1952), and Scheflen (1973).
They worked with films and were therefore able to look at
the "simultaneous cooccurrence of what all interactional
partners were doing together in constructing a
communicative ecosystem in real time" (Erickson, 1986a, p.
297).

With the development of kinesics, the study of

communication came to include gestures, posture, and facial

12
expressions, among others. This group of researchers treat
communication as problematic. In other words they assume
that intentionality is not a simple concept, that it takes
work to understand what people say and mean, that it takes
effort to interpret the meaning of a message both for
analysts and for participants. A message does not carry one
particular meaning but several, and it serves multiple
functions. The sender and the receiver collaborate in
giving cues for how a message is to be interpreted. The
approach to communication taken by these researchers is to
assume that inherent in every message there are two kinds
of meanings. There is the literal, referential meaning and
there is the social meaning. The latter means that while
two people talk about something, they also address or talk

about the relation between themselves. Bateson (1972) says,

As mammals, we are familiar with, though largely
unconscious of, the habit of communication about
our relationships. Like other terrestrial
mammals, we do most of our communicating on this
subject by means of kinesic and paralinguistic
signal, such as bodily movements, involuntary
tensions of voluntary muscles, changes of facial
expression, hesitations, shifts in tempo of
speech or movement, overtones of the voice and
irregularities of respiration. (p. 371)

At the same time as something is being talked about
and implicit references made about the relationship between
those engaged in talking, the participants tell each other

what is going on. This might seem a strange proposition to

13

make. It might seem as if we do not know what we are doing.
If one is having breakfast, one is having breakfast. If one
is taking a course, one is taking a course. The issue is
not about the official label of an event, but rather the
different sequences or chunks of which each event is built.
What is called "worktime" in a classroom is sequences or
segments of "getting ready: focused worktime activity: wind
up: clean up" (Florio, 1978, p. 69). Each sequence is seen
in the behavioral displays of the participants, that is, in
their postures, their gaze, their words. These behaviors
serve reflexively to create and to cue the definition of
situation and hence the rights and duties of participation
(as well as the range of improvisatory options) at any
point in time.

Within each sequence the participants occupy certain
communicative roles. According to Erickson and Shultz

(1982):

In communicative terms, a :91; is the set of
rights and obligations regarding ways of acting
and ways of being acted toward which is possessed
by an individual occupying a particular social
identity. As performed social identity can change
from moment to moment during face-to-face
interaction, so can communicative rights and
obligations of the individual change from one
moment to the next. Participatigg_§§;ugture can
be thought of as the complete set of
communicative rights and obligations in the roles
of all those engaged in interaction at any
moment. (pp. 17-18)

14
The transition from one sequence to another is not
explicitly stated, "Now we have finished the ‘getting
ready' phase and we are focusing on the worktime activity."
Rather this is said implictly by various linguistic,
kinesic and prosodic cues whose meanings are negotiated
verbally and non-verbally by the participants.

The purpose of talking about an event as consisting of
various sequences is to illustrate the term contgx . It is
important to stress that context is not meant here to be
what surrounds actions or events, but rather the actions
themselves, the actions taken by the participants at a
particular place, during a particular time, which
constitute the event. The word context is derived from the
Latin verb ggnggxtere which means "to weave together
separate strands" (Erickson, 1986c, p. 19). In other words,
each event is socially organized by the participants in
that they continuously take account of each others'
actions.

This is not to be confused with the traditional
understanding of the concept of equality. It rather means
that all involved contribute equally to the event at hand,
but do so in different ways. For instance, when one person i
has selected to speak, and the other stops what she is
doing and shows that she is paying attention to what she

hears and sees, she "enables" the speaker to have the

15
floor. The shift from one context to another is also

jointly accomplished.

'za '0 es
Gumperz’(1977) notion of contextualization cues is
important to understand how meaning is negotiated in a
situation. It points to the interpretive work of both
speakers and listeners. Erickson and Shultz (1982) state
that we continuously tell each other what is going on, what

context is in play for the moment:

People of varying ages and cultural backgrounds
all seem to be actively engaged while they
interact, in telling one another what is
happening as it is happening. This can be called
the W by means of
‘contextualization cues'... what signals are used
and how the signals are employed and interpreted
by the interactional partners ... may vary ...
But some ways of telling the context seem to be
present in all instances of face-to-face
interaction among humans. People seem to use
these ways to keep one another on the track, to
maintain in the conduct of interaction, what
musicians call ‘ensemble' in the play of music.

(p. 71)

By asking the practical and methodological question
"When is a context?" Erickson and Shultz (1981, 1982)
describe how people in face to face situations create and
move in and out of different contexts through changes in
postures, tone of voice and gaze. The cues that Erickson

and Shultz refer to consist of changes in the rhythmic

16
organization of speech and body motion (Erickson & Shultz,
1982), speech prosody (Gumperz, 1977), postural positioning
(Scheflen, 1973), and proxemics or interpersonal distance

(Hall, 1966).

genxersatien_Analxsis

Another school of microanalysis of interaction has
contributed different but complementary insights into the
collaborative work by participants in face to face
encounters. Sociologists developed a method called
"conversation analysis" (Sachs, Schegloff, & Jefferson,
1974) to understand how and why conversations are or become
organized the way they do. They worked with audiotapes and
focused their attention on the vocal reactions of listeners
to speakers and vice versa.

Among their contributions are the formulation of
principles governing who gets to talk, that is, principles
of turntaking, and the notion of adjacency pairs as an
organizational device used in conversation (Sacks,
Schegloff, & Jefferson, 1974). Certain types of utterances
have been found to occur in ordered pairs: a question leads
to an answer, a greeting to a greeting. These findings
arose largely from work with audiotapes, not videotapes.

This might have led, in Erickson's (1986a) view,

to their theoretical emphasis on adjacency
relationships of cooccurrence across real time -

17
on pairings of antecedent and consequent

utterances by interlocutors who exchange turns at
speaking. (p. 298)

Conversation analysts stress vocal communication. But
Goffman (1981) points out that "there are lots of
circumstances in which someone giving verbal orders or
suggestions expects something nonlinguistic as a response"
(p. 40), and calls physical doings "nonlinguistic deeds"
(p. 37). This is a notion important in the study of
physical therapy as the purpose there is to instruct, make,

or help a patient do some physical movement.

Communication as an Overriding Principle
in the Study of Physical Therapy Practice

By stressing the similarities between the patient and
the therapist in communicative terms, one is likely to find
a shift from context to context. One is likely to find that
at one moment the therapist leads, at another the patient.
The treatment situation might therefore be depicted in a
different way. We will then expect to see actors actively
engaged in each session, actors whose speech is meaningful
and situated, that is, spatially and temporally located.
This "meaningfulness" as a feature of interaction is
something that is "actively and continually negotiated, not
merely the programmed communication of already established

meanings" (Giddens, 1986, p. 105).

18
By locating the treatment situation in its proper

space and time we will see how

the anticipations of the responses of others
mediate the activity of each actor at any one
moment in time, and what has gone before is
subject to revision in the light of subsequent
experience. (Giddens, 1986, p.105)

We also see that a lot of what is happening is
interpreted and defined quite differently. We see that the
actors judge the ongoing treatment differently. What the
therapist considers a good trial, is not good enough for
the patient. Moments of disagreement, moments of confusion
and the untangling of them are therefore to be expected.

The title "Physical Therapy as Communication"
indicates a particular way of thinking about physical
therapy and communication. Communication is here
conceptualized as carrying multiple meanings, expressed
both explicitly and implicitly, vocally and non-vocally.
Considering communication as concrete allows for its
accessibility to examination. In fact, because of its
physical nature, kinesics may be even more important in a
physical therapy session than they might be in some other
sorts of face to face interaction, as carriers of both
social and referential meaning. Consequently, any
observable action by a patient or a therapist merits

investigation. Talk is one form of communication, but the

19
use of hands as part of the treatment is also part of the
communication. Gaze, postural configurations, movements,
gestures, and facial expressions are all part of
communication in the therapeutic session. In other words,
the use of a particular treatment technique represents one
form of discourse. The "ordinary" conversation the patient
and the therapist engage in represents another.

Finally, and most importantly, according to Bateson's
(1972) view of understanding behavior or actions, it is
necessary to assume that participants communicate
something. This implies a focus on relationships and not on
isolated factors. In other words, when looking at treatment
situations what the therapist says cannot be isolated from

what the patient does or says and vice versa.

The Purpose of the Study

The purposes of this study are to uncover what goes on
in treatment situations, to examine how the patient and the
therapist jointly construct sessions, and to discover how
the two experience and interpret what is going on within
the sessions. Little is known about what constitutes a
treatment session, about what happens between a patient and
a therapist, and some researchers tend to refer to the
physical therapy session or the therapeutic intervention as

a "black box" (Jensen, Shepard, & Hack, 1990, p. 315). The

20
same is true for doctor-patient encounters. When talking
about future research in doctor-patient relations Korsch

(1989) states that,

Clearly the ultimate goal will be to arrive at a
body of knowledge that deals with the essential

features of what goes on between physicians and

patients, and that applies to clinical practice.
(p. 251)

This explorative study aims to arrive at some features
that are essential to the field of physical therapy. It
therefore considers the patient’s diagnosis as equally
important as the therapist’s treatment technique; the
patient's perceptions of what is going on as equally
important as the therapist’s: what the patient says as
equally important as what the therapist says. By staying
close to the ordinary doings in clinics and by using a
language which is familiar to practitioners, the hope is to
provide a new description of physical therapy practice that
is still recognizable in terms of current research and
practice. For instance, the calling of the therapist by her
first name but the patient by her last, as is done at the
research site, is also done in this thesis. The word
"patient" for the woman who is seen in physical therapy is
not something she calls herself. However, it is customary

at this particular clinic and therefore adopted here.

21
MW:

The thesis is organized into three sections. The first
two sections contain three chapters each. Here, the content
of each section and its chapters is briefly summarized.

The first section describes the intellectual roots of
the study. Chapter one outlines the theoretical framework
for the study, and chapter two reviews two fields of
literature. One pertains to the physical therapy
profession, the other the medical diagnosis of frozen
shoulder. Chapter three restates the purposes of the study
and reports its questions, original as well as emergent,
and its methods.

The second section describes and analyzes the findings
of the study. Chapter four reports on how a session comes
to be organized around a specific diagnosis and a specific
treatment technique. Chapter five gives a detailed account
and an analysis of six brief episodes during which the
patient and the therapist suddenly seemed quite confused
about how to proceed. This chapter ends with identifying
some of the rules that organize the treatment and that the
patient and the therapist adhere to most of the time.
Chapter six approaches the same talk that had been analyzed
previously, but looks upon it from other perspectives. By
assuming that physical therapy sessions serve multiple

functions and can be beneficial from a psychological as

22
well as a pedagogical point of view, evidence of both were
found and are discussed.

Section III, which contains only chapter seven,
summarizes the findings, draws conclusions from them, and
outlines recommendations for how practicing physical
therapists and researchers alike might, in their work, use
elements from both the research methods that have been used
in this study and the findings themselves. The benefit of
adopting a social constructivist's view in their work is

argued.

CHAPTER TWO

REVIEW OF THE LITERATURE

This literature review is divided into three major
parts, each with a separate focus. The reason for this is
that physical therapy is strongly influenced by the two
disciplines, medicine and psychology. Scientific findings
from one usually exclude findings from the other. In other
words, when referring to the field of physical therapy, the
patient's medical diagnosis is often given a subordinate
role in the more psychologically oriented literature. The
clinical research concerning the diagnosis itself gives, on
the other hand, little attention to the person who is the
"carrier" of the condition and her/his relationship with
the therapist. As the purposes with the research differs,
this separation is a natural consequence.

In order to give due credit to the knowledge available
concerning psychological issues as well as medical matters,
the first part provides a background of the physical
therapy profession and discusses present concerns such as
models of practice, psychosocial aspects of practice, and
the role of communication. The second part is a description

of the shoulder joint, and the third part has as its focus

23

24
medical findings regarding the diagnosis of frozen

shoulder.

Part I

Overview of the Physical Therapy Profession

In order to contextualize the present study of
everyday practice of physical therapy in the United States,
this part is introduced by a brief description of the
profession, its background, development, and goals. As the
profession is in the midst of changes, three major trends
that have been distinguished are discussed. Briefly, these
trends concern striving toward full professional status,
striving toward establishing physical therapy as a clinical
science, and striving to improve patient care by arguing
for the incorporation of communication skills courses into
the curriculum. In addition to these trends, this review
has been guided by two meta-questions: How is the social
"reality" of physical therapy practice conceptualized and
described? How are the patient and the therapist portrayed

in medical and psychological literature?

a s 1
Physical therapy received its professional status in
the United States in the beginning of the 20th century.

Advances in bacteriology, immunology, and surgery led to

25

the need for more medical personnel. Particularly, the
physical therapy profession was founded to "provide
restorative services to persons who suffer physically
handicapping conditions" (Hislop, 1975, p. 1075). The first
physical therapists assisted orthopedic surgeons. Many were
also engaged in treating patients with poliomyelitis.

During and after World War I traning programs were
developed both at Harvard University and at military
hospitals. The first formal curriculum in physical therapy,
a four month long program, was offered in 1918 (Yarbrough,
1986). By the early 19205 the American Physical Therapy
Association (APTA) was founded (May, Bing, Ballard,
Luckhardt, & Barney, 1982).

The same association stated in 1979 the competence to
be expected by a physical therapist in a Model Definition

of Physical Therapy for State Practice Acts:

Physical therapy means the examination,
treatment, and instruction of human beings to
detect, assess, prevent, correct, alleviate, and
limit physical disability, bodily malfunction,
and pain from injury, disease, and any other
bodily and mental condition, and includes the
administration, interpretation, and evaluation of
tests and measurements of bodily functions and
structures: the planning, administration,
evaluation and modification of treatment and
instruction, including the use of physical
measures, activities, and devices, for
preventative and therapeutic purposes: and the
provision of consultative, educational, and other
advisory services for the purpose of reducing the
incidence and severity of physical disability,
bodily malfunction, and pain. (Yarbrough, 1986,
pp. 142-143)

26
The emphasis upon restoring somebody else's physical
function is also to be found in the writings by May et al.

(1982). They state that physical therapy is concerned with

the prevention or management of human
dysfunctions or abnormalities arising primarily
from deficits in motor, sensory, and
physiologically support systems. Practice is
directed toward preventing disability, relieving
pain, developing, improving, or restoring
function. (p. 222)

In addition to providing appropriate service to
patients, claims are raised that research needs to be
carried out to prove the benefits of physical therapy.
Another reason for the call for extensive research
activities is to establish physical therapy as a clinicei
ccience (Currier, 1984: Dean, 1985: Peat, 1981). During the
last 20 years, there has been increased emphasis upon
defining the unique DQQX_Q£_KDQE1§QQQ that physical therapy
as a whole encompasses (Dean, 1985).

In 1977, APTA received status as an independent
accrediting agency for physcial therapy programs from the
United States Office of Education and the Council on Post-
Secondary Accreditation. The collaboration with the
American Medical Association from 1956 regarding
accreditation was over. This is considered an important

step away from the domination the medical profession

27
traditionally has held over physical therapy practice
(Yarbrough, 1986).

The number of physical therapists has grown rapidly.
In the United States there were 1,160 physical therapists
registered in 1940: 6,242 in 1960: 10,919 in 1970: and
25,000 in 1980 (Peat, 1981, p. 171). In 1984 the number had
increased to 40,200, with the educational program averaging
four and a half years. By 1990, all programs will be
converted to graduate programs (Yarbrough, 1986).

Traditionally, a referral must be obtaind from a
physician before a physical therapist may legally treat a
patient. The therapist is also required to report back to
the physician the results of the treatment. In spite of the
fact that physical therapists today belong to a group of
health professionals who maintain relatively complete
control over their own pace of work and selection of
treatments, they remain "subordinate" to or limited by the
medical profession (Miles-Tapping, 1985).

However, Miles-Tapping (1985) does not consider
physical therapists to be representative of so-called
"paramedical" workers or "paraprofessional" occupations
that lack autonomy: she claims that the work physical

therapists do supports this since

Most physiotherapists think their jobs are
moderately autonomous. They accept referrals from
physicians, but perform their own assessment of
the patient’s problems, plan and execute their

28

treatments, and evaluate the outcomes themselves.
(p. 290)

The actual practice of physical therapy has been
dominated by the medical profession in that physicians have
always viewed physical therapy as an adjunct to medicine,
much like nursing (Yarbrough, 1986; Thornquist, 1988).
Increased autonomy, that is, increased degrees of
independence or discretion, is an important goal to obtain
for physical therapists working in the modern health care
system (Yarbrough, 1986), in order to utilize the growth of
knowledge and of treatment techniques specific to the
professional domain. This striving toward full
professionalism in the United States led to a proposal that
physical therapists should be allowed to treat patients
without the mandatory physician referral. This proposal was
passed by the House of Delegates of the APTA in June 1979.
Still, most patients seen by therapists are referred by
physicians.

Another measure of professional autonomy is, however,
the extent to which physical therapists are directly and
personally responsible to their patients (Yarbrough, 1986).
Sim (1985) states that in the working situation it is
natural that the therapist is the judge of the needs of the
patient. This is a delicate issue that has not received

much attention in the literature.

.1.
_

29
Medicine continues to exert influence upon the
profession, in that the "medical model" still dominates the
physical therapist’s view of what counts as disease and as
knowledge (Miles-Tapping, 1985). The medical model,

according to her,

describes a way of looking at the world and at
illness that identifies deviance as a disease and
as potentially treatable or curable by drugs,
surgery, or other forms of individually applied
medically sanctioned therapy. (p. 291)

Medical science influences also physical therapy
education since it is centered around physical,
physiological, and biomechanic aspects of human health and
illness (Lewis & Schaefer, 1986). Physical therapists thus
have good knowledge of basic sciences and treatment
techniques (Yarbrough, 1986), but are less versed in the
behavioral sciences.

To summarize, medicine has influenced the profession
in several ways. It has affected the curriculum, where the
basic sciences dominate. It has led to therapists'
acceptance of the biomedical way of viewing disorders and
diseases. Within practice, therapists have adopted the
procedures physicians use when seeing patients. These
‘procedures include taking a case history, doing
examinations, treating and evaluating patients. In

research, as in medicine, only quantitative methods are

30
considered scientific. Administratively, patients are still

referred to the therapist by a physician.

u2dels_2f_2hxsical_1heraex_£raetiee

Being a profession that lies between "the caring model
of nursing and the curative role of medicine" (Sim, 1985,
p. 21), several authorities in the field are concerned with
identifying what physical therapy "is:" what the essence or
general character of the profession is; how to best
describe its uniqueness. Attempts to define the physical
therapy profession vary from providing models (Dean, 1985:
Hislop, 1975: Tyni-Lenné, 1983), to emphasizing certain
issues in the field (Davis, 1986: Payton, 1986: Ramsden,
1986: Shepard, 1986), to giving fictive examples of
practice along with theoretical considerations (Purtilo,

1978).

Ih2_Hi§l22_MQQQl.QI.2QLhQBiD§§inQQ¥
Hislop (1975), one of the first to articulate the need

for a common conceptualization of the profession, states:

Physical therapy is knowledge. Physical therapy
is clinical science. Physical therapy is reasoned
application of science to warm and needing human
beings. Or it is nothing. The precise role of
science in physical therapy is not often
understood and no coherent philosophical overview
exists to guide the growth of the profession. (p.
1071)

31

Hislop bases her model of physical therapy primarily
on pathokinesiology or "faulty" movements as the
distinguishing clinical science of the profession and
secondarily on the skill of therapists to place exercise on
its proper scientific foundation.

Motion is thus considered an important concept. By
looking at man as a natural system, where motion occurs and
can be disrupted, the following hierarchical levels or
subsystems are identified as related to physical therapy.
There are'the levels of cells, tissues, organs, systems (as
the nervous system), persons, and families. Motion can be
disrupted on any level. Physical therapists can influence
the upper and the lower levels, but possess tools for
intervention only at the middle levels, according to
Hislop. By some form of controlled exercise or stimulus to
induce movements, physical therapists aim to restore motion
homeostasis or to "enhance the adaptive capacities of the
organism to permanent impairment of loss" (p. 1073).

Hislop defines physical therapy as

a health profession that emphasizes the sciences
of pathokinesiology and the application of
therapeutic exercise for the prevention,
evaluation, and treatment of disorders of human
motion. (p. 1076)

Along with the intervention tools a therapist uses in

treatment situations, Hislop adds humanism as an intrinsic

32
attribute of therapy. Building upon Hislop’s notion of
treatment as being the essence of physical therapy, Dean
(1985) adds another factor, optimal treatment outcome, when
presenting a psychobiological adaptation model for physical
therapy practice.

WWW

Treatment outcome is supposed to reflect "the
interaction of factors relating to the patient and the
therapist" (Dean, 1985, p. 1061). Psychobiological factors
are defined as primary factors and psychosocial factors as
secondary ones with respect to the patient profile. Primary
and secondary factors relating to the therapist are
clinical factors and educational and professional factors.
Of the primary psychobiological factors, three are related
to the patient’s condition and include the anatomy, the
physiology, and the pathology of the condition. The fourth
one, psychology, refers to the patient's psychological
traits. For each of these, there is a matching therapeutic
intervention such as physical modalities, patient
education, therapeutic techniques, and prevention
strategies. This "fit" is essential for arriving at an
optimal treatment outcome.

One of Dean's goals is to include a biopsychosocial
perspective of the patient with the clinical one and this

is covered in the model. However, the therapist is only

33
portrayed as a professional being, armed with treatment
strategies. The therapist has all the knowledge, the

patient none.

Ih£_2h¥§iQLh£I§P¥_MQQ§l

Tyni-Lenné’s model (1983) also takes Hislop’s original
writings about physical therapy from 1975 as a starting
point when describing a physiotherapy model. Physical
therapy is here seen as a process, with the interaction
between the patient and the therapist as the central theme.
The process involves several choices. Problems continually
have to be resolved. The actions that are carried out by
the therapist during the physiotherapy process are all
purposeful or intentional.

Using a systems theory approach, the process is
described with principles from problem solving and decision
making theories. The patient and the therapist are
primarily portrayed as two subsystems that influence each
other. All kinds of behavior are displayed in this process,
including cognitive, affective, and psychomotor, with
psychomotor behavior being considered particularly
complicated.

goal. oer 31

There are several similarities in Dean's and Tyni-

Lenné's models. Logic, rationality, and intentionality are

34
seen as fundamental to physical therapy practice. Nothing
is left to chance. Both stress treatment outcome as being
of central importance. Dean proposes that for each problem
or element a patient brings, there is a corresponding
therapeutic intervention available. Tyni-Lenné "guarantees"
proper outcome through adherence to a step by step sequence
of decision makings. Implicitly, there is an assumption
that every patient will perceive the therapist's actions as
meaningful.

Although both try to describe the patient and the
therapist as "people," Dean talks about them as factors,
Tyni-Lenné as subsystems. Both portray the patient as
bringing only problems, the therapist as providing all the
solutions. Thus, we see that intentionality and knowledge
belong to the therapist, but not to the patient.

While Dean and Tyni-Lenné talk about treatment as
being constituted by two people, the interaction as such is
only given minor attention. Their models are based strictly
on theoretical studies. No empirical findings support them.
The models by Tyni-Lenné (1983) and Dean (1985) point to
physical therapy as intentional actions, assuming that they
are perceived as such by each patient. Built into each
model is the implicit promise that if the appropriate steps
are taken, positive outcome is guaranteed.

This way of looking at physical therapy is yet another

attempt to arrange all the different factors that can

35
influence the outcome of a treatment into one single
conceptual model.

Both state that their intentions with the proposed
models are to improve the profession, both theoretically
and practically. For this to be accomplished, therapists
are recommended to start thinking and acting in terms of
their proposed models. However, questions must be raised as
to whether these idealized models of physical therapy are

useful in actual practice.

ee ' 'ca ' 5

Recent work by Jensen et a1. (1990) stresses the
necessity for observing treatment sessions in order to
understand the practice of physical therapy. They report on
an observational study, the purpose of which was to
"develop a conceptual framework and a data collection tool
to begin a systematic analysis of the work of the physical
therapist" (p. 314). They present a conceptual framework
that is divided into three levels. Level I consists of the
physical therapist's professional characteristics, the
patient's characteristics, and organizational factors such
as type of setting, payment system, geographic location,
other personnel, and time constraints. On Level II there
are the tools the therapist has available. These are
communications techniques, manual techniques, and

modalities. At the third level is

36
the dynamic intervention, or ‘black box' or
filter, that all of the identified Level I and
Level II factors are filtered through. At the end

of this filtration process is the patient
outcome. (p. 315)

This framework suggests that the therapist, the
patient, the setting itself, and the circumstances during
which treatment occur are all factors that affect the final
patient outcome, but this is dismissed in the discussion.
What is focused upon is rather the more or less effective
ways of working with patients that the therapists they
studied displayed.

Eight physical therapists with varying degrees of
experience, working at four different adult outpatient
orthopedic settings, were observed by two researchers.
Written fieldnotes and transcribed audiotapes of treatment
sessions were the data from which coding categories of the
patients' and the therapists' verbal communication were
developed. Five themes emerged that the researchers found
to be present in all sessions and within which they could
see a differenc between the novice and the experienced
therapist in the study. The themes concerned how treatment
time was allocated: the type of information gathered from
the patient and the therapist’s use of it: the impact of
the therapeutic environment upon the therapist’s work, such
as handling interruptions and tasks outside of direct

treatment: the degree of responsive therapeutic

37
interaction, that is, to what extent therapists integrated
"verbal encouragements and tactile cues" (p. 321): and the
therapist's integration of nontherapeutic interaction with
therapeutic interaction. Social interaction is considered
nontherapeutic.
This study of naturally occurring treatment sessions

refrains from attributing patient outcome to the treatment
technique being used and seeks to uncover the complex

interactions that constitute treatment sessions.

Psycnoscciei Aspeccs cf Enysicel Inezeny Eneccice
In developing an integrated model that provides a

place for the role of therapist-patient interaction, one
volume of the research series, ciinics in Physical Therapy,
devoted to psychosocial aspects of clinical practice
(Payton, 1986), is worthy of special review. It pays
particular attention to the concepts of purposefulness or
intentionality, the portrayal of the patient and the
therapist, and, to some extent, the distribution of
knowledge.

Payton (1986), when writing about the acquisition of
communication skills, states from the outset that
intentionality is the key concept for turning ordinary
communication skills into professional communication
skills. Communication skills, he argues, ought to be part

of the therapist’s overall technical competence. The

38
therapist should be able to choose deliberately choose when
to use certain kinds of listening skills and when to use
influencing skills. These skills, along with the category
"focus," refer to the Ivey Taxonomy of Communication
Skills. A microskill model has also been developed, tested,
and found useful in the fields of counseling, nursing, and
business management (Payton, 1986). Payton's chapter is
based upon this model and its relation to and usefulness in
physical therapy practice.

Payton argues that,

Just as each element in a treatment program is
evaluated for its effectiveness so each statement
or question in a communication is evaluated for
its effectiveness in achieving the purpose for
which it was chosen. (p. 2)

Payton goes on to stress the conscious intentions of
the therapist's sayings and doings. For instance, the
therapist's non-verbal behaviors are important in
encouraging the patient to "speak openly and freely and to
stay on relevant topic" (p. 5). And reflective skills are
used to assist the patient to "see his own thoughts,
feelings, or meanings more clearly" and through this
patients might be able to "clarify and refine their own
thinking, feeling, and valuing" (p. 7).

Throughout Payton's chapter, we see the therapist as

actively being able to utilize a variety of skills in order

39
that the patient might understand himself more clearly. The
therapist is also portrayed as shifting between the roles
of a physical therapist and a modified version of a
psychotherapist. For example, Payton asserts that
"Instruction is at the heart of much physical therapy. From
his professional knowledge base, the therapist tells the
patient and his family what to do and how to do it" (p.
19). Confrontation skills can be used to help the patient
"to clarify his own thoughts, feelings, and meanings so
that his behavior is consistent" (p. 15).

We see a therapist who knows exactly what a patient
should do and how to do just that. The therapist also knows
how to help the patient clarify his feelings and meanings.
From this we can infer that the patient has no knowledge of
what "to do" before seeing a therapist: the patient's
behavior is many times inconsistent. Granted that Payton
does not explicitly state the fictive patient’s condition,
nor claim that all patients' behavior is "inconsistent,"
nonetheless we see the therapist as knowledgeable and the
patient as "having problems."

Ramsden (1986) portrays the therapist in a similar

way:

It is standard behavior for health professionals
treating patients to observe patient behavior,
make judgments about that behavior, decide on a
course of action, then note the results and
evaluate them. (pp. 58-59)

40
Ramsden also mentions another dimension of physical
therapy. "Often in treatment what we are doing or what we
are saying may cause the patient discomfort" (p. 69). She
reports on a discussion with a group of therapists, which
revealed their serious concern about the legitimacy of
their own particular way of interacting with patients.

By using case studies to illustrate how therapists can
draw on various theories, such as Erik Erickson's
Psychosocial Theory of Development and Maslow’s Needs
Hierarchy, Ramsden suggests how a patient’s motivation
pattern and his or her level of psychosocial development
can be judged. It is clear who is in charge. The therapist
is "the expert and in control of the environment" (p. 38).
A slightly troublesome treatment situation involving a
young man and a young female therapist is commented upon in
the following way. "Ms. Morgan (the therapist) seems to be
defensive, protecting her turf and her control--for what?
It is her turf and she is in control" (p. 58), while the

patient is

assertive in a subculture that expects passivity.
He wants control where others want him to be
passive. He appears to have a strong need for
achievement and quick results when the situation
calls for careful pacing and slow progress in
step with healing. (p. 58)

41
This sequence informs us that the therapist should control
the situation: the patient, who seems strongly motivated,
should be passive.

Shepard (1986) alludes to the same concept. She talks
about the therapist as being in an optimal position to
"offset deleterious effects" of the hospital environment
because, among other things, "Conversations can be turned
away from specific bodily concerns as the therapist
encourages the patient to talk about functioning in home
and work environment" (p. 78). Earlier Shepard states that
the focus of most physical therapy treatments is on
increased independent functioning and mobility, and that to
achieve this therapists work with patients’ bodies.
However, there is a possibility that such use of conscious
strategies to make the patient not talk about the body
while actually using it in concrete treatment situations
might be counterproductive to achieving these goals, an
issue raised by this dissertation in chapter seven.

Davis (1986) states the following when talking about

health care delivery:

Health care professionals often discover what is
wrong with a patient after careful and
cooperative examination. Clinicians can explain
causes of symptoms, referred pain, trigger
points, arthritis, spasticity, reflex bound
behavior, etc. They understand, to a great
extent, what causes many symptoms and know
various ways to treat problems. Most of the
therapists' efforts are rewarded with predictable
outcomes, such as relief of pain, correction of

——

 

42

posture, or gain in endurance, strength, or
agility.

This is reassuring to our patients who do not
understand what is happening to them. Their
symptoms are, to a great extent, beyond their
knowing or control. In sum, health care workers
provide patients with the reassurance that what
is happening to them is not part of the unknown,
nor beyond control or influence, but part of the
rational world. Their explanations connect the
unknown and seemingly uncontrolled phenomena a
patient feels with the remainder of the patient’s
experience. (p. 124)

Although Davis’ main focus is on how values influence
the care of patients, in the above section she describes
patients as understanding and knowing little about their
own bodies.

In summary, the book is intended to shed light upon
issues that are, by their very nature, difficult to grasp.
Although the writers alternate between giving concrete
advice about how to behave in a "humanistic way" (Davis)
and talking about the patient and the therapist in general
terms, there are no contradictory statements about the
therapist’s good intentions, purposeful actions, and
professional knowledge. The patient is pictured as bringing
problems, both physical and psychological, to the scene.
The authors claim the patient lacks knowledge, but this can
also be interpreted to mean that the patient lacks the
cneznniec;e_kncnlecge. The patient is often "not motivated"
(Ramsden), or "has a strong need for achievement when the

situation calls for careful pacing" (Ramsden, 1986, p.58),

43
or can be helped in clarifying his feelings and thoughts
(Payton, 1986).
Another book in the same field, Heci§n_£;cfe§§icnel
Recient_1n§ezeccicn, by Purtilo (1978), is directed to

health professionals with the purpose of describing
premises and methods for achieving effective interaction
with patients. Facts from studies in biomedicine and the
behavioral sciences are illustrated with examples of
different situations, where staff interact with patients.
Instances of both good and problematic encounters are
provided, adopting both the patient’s and the therapist’s
perspectives. Explanations for their behavior are given,
and, when needed, suggestions for appropriate behavior and
effective communication. By referring to the patient and
the therapist not only as roles, but, equally frequently,
as human beings, the examples sound true to life. However,
as stated in the preface of the book, all the examples are
fictive. Not one of them is based on any empirical study.
And by providing recommendations for appropriate behavior
an illusion is conveyed, namely that treatment situations
should be and can be free from conflicts. It all depends on
how the therapist handles the situation.

Other researchers address issues similar to those
brought up in the above reviewed books. This body of
literature can be divided into three groups. One discusses

concepts considered pertinent to physical therapy, such as

44
psychotherapy (Stewart, 1977), psychological theory (Davis
& Kenyon, 1981: Goldin, Leventhal, & Luzzi, 1974), and
basic relationship skills (Hamilton-Duckett & Kidd, 1985).
Another group describes the content of training programs in
social skills (Dickson & Maxwell, 1985) and in
microcounseling (Saunders & Maxwell, 1988). A third group
reports successful outcomes of courses aimed at improving
counseling and therapeutic skills mainly among physical
therapy students (Levin & Riley, 1984: Payton, 1983:

Schultz, Wellard, & Swerissen, 1988).

o ' as a t

Common to those who argue for improvement of
communication as a whole, as well as improvement of
counseling skills is that the talk they are concerned with
does not include the instructions that accompany any
treatment. These are to be found in textbooks regarding
specific treatment techniques, for example, the book
written by Knott and Voss (1968). Instead they discuss the
talk that "surrounds" the physical treatment itself. They
define talk either as interviewing skills, communication
skills, social skills, interpersonal helping skills, or
counseling skills. Talk is thus considered a tool to
receive appropriate information from the patient and a
technique to help the patient on a psychological level.

There are few, if any, conflicting opinions of what needs

45
to be improved by physical therapists, such as interviewing
skills, or how those skills should be taught.

Characteristically, talk is placed in the domain of
psychology. In doing so and, at the same time, eliminating
the ”instructional talk," the authors indirectly state the
following. First, physical therapists are in a position
such that while helping patients recover from physical
traumas, they can also help the patients accept and deal
with the associated psychological traumas. Second, the talk
that is part of the instrumental or technical aspects of
the profession (that is, the talk that is closely but
implicitly connected with the patient’s medical diagnosis)
is separate from other forms of talk. Third, the impact of
this "instructional talk" upon the patient is discounted or
reduced.

This body of literature thus extends physical therapy
situations to being therapeutic in more than one sense. But
the portrayals of the patient and the therapist remain
unchanged. The therapist, in learning communication skills,
is even more in control of what goes on. The patient, who
remains a problem, is still depicted as having little to
contribute to the treatment itself and the recovery

process.

46
Wm

A contrast to this dominant way of looking at physical
therapy situations is present in the work by Engelsrud
(1985, 1990). First, she claims the essence of physical
therapy to be the living body and its movement. Second, it
is through them the therapist gains access to the patient’s
world. Third, in looking at physical therapy from a
philosophical perspective, the assumptions or definitions
of human beings are that they are living, acting, and
experiencing subjects. As a consequence, they cannot be
directed, manipulated, or predicted. If human beings are
looked upon as objects, they are already defined,
unchangeable, and mechanic.

This existential perspective points also to people’s
ability to reflect upon their experience. We are not
passive recipients, nor in the hands of external demands
and conditions. We are able to reflect upon the experience
of our bodies. In a dualistic perspective, the body, a non-
living object, is separate from our experience of it.

Engelsrud cautions us:

To learn about the ‘dead body,’ and to accept
research findings based on studies of the same
‘dead body,’ without making references to the
body as it is lived and active, might bring about
an objectification of physical therapy. Through
this both the therapist and the patient are
presumably turned into objects, which can be
standardized. (p. 51, my translation)

47

Engelsrud refers to the work of Merleau-Ponty and
Sartre. According to Merleau-Ponty (1962), the condition
for a human being to be in the world as a subject is that
the body must "be lived" and acknowledged frankly and
immediately. Sartre’s concept of the body as "being-for-
itself" implies that human existence is a condition,
characterized as being and experiencing each moment. These
notions are important to consider since the participants in
a physical therapy relationship interact through the body
and the movements (Engelsrud, 1990).

In a previous study, Engelsrud (1985) examined the
assumptions therapists hold regarding one particular aspect
of therapy, namely, what working with a living body means.
By closely analyzing three books in the field of physical
therapy, she found that physical therapists clearly prefer
seeing the body as separate from the mind. Thus a
perception of body and mind as separate entities prevails
in the field of physical therapy, in spite of the fact that
psychology is the discipline, apart from medicine, that has
always exerted a strong influence upon the profession

(Engelsrud, 1985).

EBEEEZY

Those researchers who explicitly address psychosocial
aspects of the profession indirectly claim that they want

to move away from identifying the therapist with her

48
treatment technique and the patient with her diagnosis.
They want to talk about the two as human beings. They
proceed in the following way. After first establishing the
humanity of the patient and the therapist, in other words
bringing up their silimarities, they move on to make
distinctions between them. Clearly, but indirectly, they
define the different roles of the two. This is found in the
case studies they provide, selected to exemplify something
else. They portray the therapist as having expert
knowledge, as having the right to tell a patient what to
do, as being the one who is in control of the treatment
situation. Thus, the therapist has intentions. She acts
rationally.

This emphasis upon the therapist’s purposeful
activities and control is not to be confused with
professional responsibility. But the ways the terms
"purpose", "intention," and "control" are used here imply
more than what therapy alone demands. The patient is
portrayed as a carrier of problems. The patient is assumed
to understand little of what has happened to her/him or
what is happening. The patient is depicted as either a
passive recipient of treatment, that is, not motivated, or
someone who wants to do too much. The patient has, in a
sense, nothing to offer to the recovery process except

information about the problems.

49

The patient’s body and mind are talked about as
separate entities. The patient brings first of all bodily
problems to the therapist for rehabilitation. Eventual
negative psychological consequences, brought on by the
injury itself, should also be treated. Accordingly,
therapists are recommended to learn various psychological
models to help in evaluating the patient’s dilemma. Along
with this, counseling skills are deemed necessary. Various
forms of communications skills, referred to as "technical
competence" should also be mastered. The kind of
communication that is discussed and recommended is mostly
vocal in nature. It is considered something deliberate. It
is dominantly and implicitly referred to as going from the
therapist to the patient, the message never being
ambiguous, the patient accepting whatever the therapist
says.

What is stressed most of all, with respect to the
patient and the therapist, is the diffenence between them.
Even if this is what caused the two to meet in the first
place, the similarities between them have received minimal
attention. That the patient also is someone who has
intentions, knowledge, and competence, albeit of different
kind from the therapist, is not mentioned. Also left out is
the fact that the patient does possess something important,

namely bodily knowledge of her condition.

50

By talking about the therapist’s knowledge and control
and the patient’s problems means focusing upon the static
roles of the two. By using fictive examples of treatment
situations the patient and the therapist are portrayed as
stereotypes. In this lies a danger. When statements about
what goes on in treatment situations are not grounded upon
empirical studies, and assumptions are made about what
might go on, it becomes too easy to prescribe how a
therapist should act toward a patient. It becomes too easy
to say what is right and wrong in treatment situations, and
to discount the patient’s participation in the recovery
process. Now, the goal behind these recommendations is to
provide best possible care. However, such descriptions of
idealized situations are quite removed from the "lived
world,“ although they prevail in the literature. What takes
place in treatment situations is not solely the result of
conscious deliberation. Spontaneous and immediate reactions
also play a part. Therefore questions of validity need to
be raised.

When turning to authentic situations, one must ask
whether patients present themselves as problems to be
solved. One must ask whether the knowledge and competence
of the patient is attended to or not. One must ask about
the patient’s contribution to the treatment and the

recovery process.

51

The kind of research that is presently carried out
tells us about the assumptions regarding physical therapy.
It is a clinical profession based on the natural sciences.
It is a profession that involves working with people and
where psychology is put to use. It is a profession that
defines communication as technology. The treatment
situations are depicted as highly rational with the
therapist assuming lots of responsibility. The purpose of it
many studies is prescriptive, in the sense that they aim at
describing how to facilitate carrying out the work of the
therapist, that is, to make the patient do things while at
the same time paying due respect to the patient. This is
not to say that what is recommended is wrong. But the
discrepancy between the writings about treatment situations
as being well organized and controlled by the therapist and
the way treatment situations look when observed is
striking. There is a need to study physical therapy
practice closely to capture or stress other features that
will influence the profession eventually.

As mentioned in the introduction to this chapter,
there is a tendency to underestimate or to discuss in
general terms how the physical injury or condition itself
influences the patient, the therapist, and the process of
treatment in the psychologically oriented literature. After
describing the shoulder joint (part II), a review of the

literature concerning the diagnosis of frozen shoulder, a

 

52
problem from which the patient in this study suffers, is
therefore reported in part III. This review includes mainly
studies that aim to identify the cause of the condition,
its symptoms, the structures that are affected, and
treatments to be offered. The latter include treatments
that can be provided by physicians and by physical

therapists.

Part II

The Shoulder Joint

As an introduction, a general description of how a
joint is build is given. The structures surrounding the
shoulder and the movements they allow the arm to do are
prerequisites to understanding the symtoms caused by a

frozen shoulder.

tu 'n

The junction of two bones is called an articulation or
a joint. Each joint is a functional unit formed by a number
of different tissues such as bones, a capsule, a joint
cavity with synovial fluid, ligaments, muscles, tendons and
bursae.

The articulate surfaces of the bones are covered with
cartilage, which ensures a better fit between the bones,

protects them, and absorbs shocks. Cartilage lacks its own

53
nerve and blood supply. It receives nourishment from the
synovial fluid, which is produced from a thin layer or
membrane of the capsule. The outer membrane of the capsule
is in some areas reinforced by thickenings, very much
similar to ligaments.

In addition, separate ligaments help hold the bones
together. The capsule encloses the joint completely. It is
rich in sensory nerve endings, reacting to tension and
pressure (Petrén, 1960, p. 176). The capsule and the
ligaments prevent dislocations of the bones and limit
possible ranges of motion. Other stabilizing forces are
muscles as they contract and tendons that cross most
joints. Other structures of a joint are tendon sheaths and
bursae. Their function is to minimize friction between
tendons or muscles and bones. In the case of a frozen
shoulder, all of the tissues that are mentioned, except the

bony structures, can be affected.

e o m J
The joint commonly considered the shoulder joint
refers to the joint between the shoulderblade (scapula) and
the upper arm (humerus). The medical term for this joint is
the scapulohumeral or the glenohumeral joint. But the
shoulder is not a single joint. It is only one of the seven
joints that form the shoulder girdle or the shoulder

complex (Cailliet, 1981). Any smooth movement of the arm

54
requires well synchronized actions of all seven joints and
their muscles. Dysfunction of any of these joints can
inhibit arm movement.

The purpose of all shoulder movements is to increase
the area through which the hand can move. Therefore the
scapulohumeral joint, which from now on will be referred to
as the shoulder joint, has a wide and lax capsule with few
ligaments. The stabilizing function of the capsule is
diminished. This in turn is compensated for by muscles that
surround the capsule almost entirely. Only the lower or
inferior part of the capsule lacks this protection. Here an
axillary fold or recess is formed due to the looseness of
the capsule. With the arm by the side, the upper part of
the capsule is taut and the inferior part is slack. When
the arm is lifted our to the side the recess is taut and

the upper part of the capsule slack (Cailliet, 1981, p.8).

WW

Many daily activities, such as taking dishes from a
cupboard, tying an apron behind the back, combing the hair,
putting on a coat, or reaching into a hip pocket for a
wallet, require, apart from lifting the arm, the ability to
rotate it. Being a ball and socket joint, although
incongruent, the shoulder joint allows the arm to move in
all directions. Starting from the anatomical position where

the arm is resting at the side of the body, palm turned

55
forward, the arm can be elevated forward, backward and
sideward. It can be rotated inward and outward. In medical
terminology forward elevation is called flexion, the return
movement extension. Backward elevation is called
hyperextension. Sideways elevation is called abduction and
the return movement is called adduction. Rotation inward is
called internal rotation, outward is called external
rotation. By bringing the arm out to the side up to
shoulder level, and there rotating the arm externally and
continuing to lift the arm, one can reach the same extreme
terminal position as when doing a full forward flexion.

With the arm at shoulder height (flexed to 90 degrees)
it can be brought horizontally in front of the body
(horizontal adduction) and away from the body (horizontal
abduction). The arm can be elevated in the diagonal planes
between flexion and abduction on the one hand, and
extension and abduction of the other hand. For those
movements there is no standard terminology.

Not considered a pure movement but a combination of
movements in the shoulder joint is the circumduction. If
one puts one’s fingertips on the same side’s shoulder and
draws a circle in the air with the elbow, a circumduction

is performed.

 

56

W

In physical therapy, movements are classified as
active or passive (Cailliet, 1981). Active movements are
carried out by the patient herself, while passive movements
are those where the therapist moves, for instance, a
patient’s arm, which has to be relaxed. In addition, the
therapist can assist the patient in carrying out an active
movement, which is called an active assistive movement.
When the therapist applies resistance to a movement, it is
called an active resistive movement. When the patient and
the therapist work to achieve an elongation of the muscular
and capsular fibers, all these movements are used in

different parts of the stretching process.

MM

Five of the nine muscles related to the shoulder joint
are considered prime movers (Cailliet, 1981). Four of these
five muscles are known as the musculotendinous cuff
muscles, m. teres minor, infraspinatus, supraspinatus, and
subscapularis. They act as rotators. They all originate
from the shoulderblade and insert upon the upper arm. The
fifth muscle is m. deltoideus, which belongs to the utmost
layer of muscles and is seen in the rounded shape of the
upper arm. Its insertion is located on the outer upper
third part of the humerus. This is one of the areas or

spots that patients with frozen shoulder find extremely

57
painful. The pain is not caused by any inflammatory
reaction of the deltoid tendon, but is "referred" from the
shoulder joint. This was perplexing to the patient in this

study who said,

Intellectually I understand referred pain, but I
don’t understand it in my heart. Why it hurts
down here (touches her right upper arm), when it
actually is up here (puts hand over
shoulderjoint). (Video I, 1/18/84)

The logic in locating pain to its proper origin is
thus gone, and it seems incomprehensible to the patient.
Apart from having pain, flexion, abduction, and external
rotation are the movements which are particularly difficult

to perform when the shoulder is "frozen."

t'on sc 3

A muscle can do two things: develop tension within
itself (contract) or relax (Rasch & Burke, 1971). Movements
will be performed smoothly and automatically, if nothing
prevents muscles from either contracting or relaxing.
Muscles that work actively to perform a movement are called
prime movers or agonists (Rasch & Burke, 1971). An example
is the biceps muscle that, when activated, bends at the
elbow. Muscles that work the opposite direction are called
antagonists, in this example the muscles that extend the

elbow. If they are activated they can prevent the flexion

58
from occurring. In order to carry out a full flexion at the
elbow, the antagonists need to be relaxed and not
shortened.

Throughout this study the patient’s forward flexion
remains incomplete. One reason for this, apart from the
effect of a contracted capsule, can be a shortening of the
muscles that bring about the extension. What is desired
then is a treatment where the extensors will be elongated
and will stop preventing full forward flexion from
occurring. The purpose of this technique, which is called
stretching, is thus to work with the muscles that are
shortened, not the muscles that perform the movement that

is restricted.

Part III

The Diagnosis of Frozen Shoulder

As the shoulder joint permits excessive mobility but
not enough stability, it provides a basis for pain,
degeneration and dysfunction (Cailliet, 1981). One of the
most common conditions that middle-aged people seek help
for in general practice is, accordingly, a painful and
stiff shoulder (Neviaser, 1980). The particular condition,
frozen shoulder, was first described in 1872 by the French
surgeon Duplay, who labeled it "periartherite scapulo-

humerale" (Bruckner & Nye, 1981). Several other terms have

59
been used since then, such as frozen shoulder, adhesive
capsulitis, periarthritis, pericapsulitis, obliterative
bursitis, and "stiff shoulder" (Cailliet, 1981). This
variety of diagnoses suggests a lack of consensus regarding
the etiology of the condition.

In his classical book about the shoulder (published in
1934), Codman writes about the frozen shoulder as a class
of cases he finds "difficult to define, difficult to treat
and difficult to explain from the point of view of
pathology" (Weiser, 1977, p.408).

Many of the published reports, if not all of them,
confirm Codman’s impressions. The frozen shoulder remains a
rheumatologic enigma (Bulgen, Binder, Hazleman, Dutton, &
Roberts, 1984). In spite of this several studies have been
undertaken to understand the etiology of the condition: to
more accurately arrive at an appropriate diagnosis: to be
able to provide optimal treatment: and to learn about the
prognosis of the condition.

Frozen shoulder is a frustrating condition, both for
the patient and the physician, writes Neviaser (1981). The
condition takes an extremely long time from which to
recover. Symptoms may last for up to three or four years,
claim some researchers. Others say that it can leave up to
70% of patients with slight but permanent restriction of

motion.

60
W

The frozen shoulder syndrom, defined by Reeves (1975,
p.193), is "an idiopathic condition of the shoulder,
characterized by spontaneous onset of pain in the shoulder
with restriction of movement in every direction. Pain is
often severe and, characteristically, disturbs sleep."

The long term study of the natural history of frozen
shoulder (Reeves, 1975) is important here because patients
were followed up for 5-10 years or until their greatest
recovery. Patients were only given analgesics to relieve
pain and were recommended to rest the arm in a sling. No
physical therapy was given during the recovery period,
apart from instructions to exercise to regain external
rotation and abduction. Reeves found the condition to

follow three consecutive stages, one of pain, one of

stiffness, and one of recovery. Ine_peinfinl_penicc lasted
for 10-36 weeks: MW. that is, the time

when no improvement took place, lasted for 4-12 months.
After this, spontaneous recovery of movement followed. Inc
zeccye;y_ne;icg took 5-26 months.

The total duration of the symptom was an average of
30.1 months. The longer the stiffness stage, the longer it
took to recover. The total time from onset to greatest
recovery was between one and four years.

Reeves reports that 40% of the patients recovered

completely, 54% were left with clinical limitations of

61
movement, and the remaining 6% suffered from functional
limitations that interfered either with their hobbies or
work. Reeves defines clinical limitation as a loss of
movement compared to the unaffected side. This limitation
does not inhibit the patients’ normal functional
activities, including work and hobbies. Binder, Bulgen,
Hazleman, and Roberts (1984a) also found, at a review 40-
48 months after onset, clinical restrictions without
functional impairments.

Pain occurs with no prior trauma. It can involve the
whole shoulder and is many times referred to the insertion
of the deltoid muscle on the upper arm. During night, pain
wakes patients up when rolling over on the affected
shoulder. The movements which are especially painful are
abduction and external rotation. The only way to relieve
pain is not to move the arm. This leads to less mobility
and increased stiffness. Thus a vicious circle is created

(Roy & Oldham, 1976).

t b t ?

There is general agreement among researchers that most
cases of frozen shoulder are idiopathic, that is, of
unknown origin. But frozen shoulder can be caused by
trauma: it can be associated with diseases such as

diabetes: it can occur after myocardial infarction (Rizk &

62
Pinals, 1984) and in connection with neurosurgery (Bruckner
& Nye, 1981).

Early studies by Simmonds (1949) and Neviaser (1945),
reviewed by Bulgen, Hazleman, Ward, and McCallum (1978),
suggested frozen shoulder to be precipitated by
degeneration of the supraspinatus tendon and to be
associated with chronic inflammation of the shoulder
capsule and of the subacromial bursa.

Neviaser found at autopsy and at surgery the capsule
to be "avascular, tense and markedly adherent to the head
of the humerus," and that there were adhesions between the
two synovial surfaces of the axillary recess, which limited
abduction. He drew the conclusion that the thickened
capsule was a result of a chronic inflammation (Neviaser,
1980).

Later arthroscopic studies (Ha’eri & Maitland, 1981)
found the joint capsule to be contracted in 60% of the
patients they studied, but no adhesions. They concluded
that causes for frozen shoulder are to be found in
structures outside of the capsule, such as adhesions of the
subscapularis bursa.

The vulnerability of the supraspinatus tendon has been
explained because of its passively supporting the humerus
in a person standing or sitting and actively participating
in abduction of the arm and in external rotation (Cailliet,

1981). Microvascular studies also show a constant relative

63
avascular area close to the insertion of this tendon
(Bulgen et al., 1978). This last finding prompted
researchers to investigate whether frozen shoulder was a
localized autoimmune reaction to the damaged supraspinatus
tendon. This is also what Bulgen et al. (1978) found, but
it has later been disconfirmed by Rizk and Pinals (1984).

There are conflicting opinions as well regarding what
methods to use to confirm the diagnosis. Rizk, Christopher,
Pinals, Higgins, and Frix (1983) and Neviaser (1980), among
others, claim arthrography to be the only reliable method,
while Binder, Bulgen, Hazleman, Tudor, and Wraight (1984b)
do not consider it to be of any prognostic or therapeutic
importance.

Bruckner and Nye (1981) report results from other
studies. No degenerations of the bony structures were to be
seen in X-rays of the shoulder joint, while X-rays of the
neck showed an increased incidence of disc degeneration C
5-6 and C 6-7, that is, the discs between the fifth and the

sixth and between the sixth and seventh cervical vertabrae.

Bersenaliwies

When no conclusive results are to be found regarding
physiological causes of certain conditions, some
researchers turn to personality studies. The assumption is
that the cause can be found in a patient’s personality. An

early study by Coventry (1953) continues to be cited by

 

 

 

64
many. Coventry describes a "periarthritic personality" as
somebody who is displaying deep-seated anxiety and apathy
(Cailliet, 1981). But, according to Caillet, low pain
threshold and disuse of the affected arm have to be
combined with such a personality for a frozen shoulder to
develop.

Fleming, Dodman, Beer, and Crown (1976) investigated
the personality profiles of 56 patients by means of a self-
administered assessment of psychoneurosis, the Middlesex
Hospital Questionnaire. The total score measures general
neuroticism, of which there are six sub-categories: free-
floating anxiety, obsessionality, depression, phobic
anxiety, somatic anxiety, and hysterical traits. They found
only that women showed significantly increased somatic
anxiety in comparison to a control group. Somatic anxiety
is defined as "a measure of the increased tendency of
patients to focus anxiety symptoms to bodily structures and
functions" (Fleming et al., 1976, p. 456). Based upon this
finding, the authors claim it to be an important factor to
consider both with respect to etiology and treatment. They
do mention, however, that Codman (1934) argued that the
personality changes seen in patients with frozen shoulder
were the result of pain rather than the cause of the
condition.

Bruckner and Nye (1981) wanted to evaluate risk

factors among neurosurgical patients, who are predisposed

65

to develop frozen shoulder. Among other tests they included
the Middlesex Hospital Questionnaire with an assessment of
the patient’s pain threshold. They found no correlation
between the development of the condition and low tolerance
for pain. They also found the sub-category depression to
correlate significantly with a frozen shoulder condition,
thus contradicting the Fleming study. The authors caution

that pain itself could have led to the condition.

nna; Ie tne Most Effective Treacnenc?

There have been numerous attempts to compare different
treatments, but there is no general agreement as to the
most effective one (Thomas, Williams, & Smith, 1980). The
treatments that have been evaluated include the use of
local or oral steroids, manipulation under anaesthesia,
ultrasonic therapy, various forms of physical therapy, and
radiotherapy, to mention only a few (Bulgen et al., 1984;
Hazleman, 1972: Thomas et al., 1980). But Hazleman (1972)
seriously questions whether any therapy alters the natural
history of the condition at all.

Many researchers report favorable results from
manipulation under anaesthesia (Haines & Hargadon, 1982:
Helbig, Wagner, & Dohler, 1983: Thomas et al. 1980: Weiser,
1977). However, it is difficult to draw conclusions from
these studies since none of them use the same diagnostic

criteria. For instance, when some studies include patients

 

66
who have suffered from shoulder pain for only one month
(Bulgen et al., 1984), one must question whether such cases
are "true” frozen shoulders.

Binder et al. (1984a) state that the prognosis for
recovery and effectiveness of therapy remains uncertain.
They assume that the conflicting results that are reported
are signs of discrepancies regarding selection of patients,
criteria for diagnosis, and criteria used for recovery.
With respect to degree of recovery, findings vary from
prolonged disability, to restriction of range of motion but
with little functional impairment, to complete recovery in
patients with "untreated" frozen shoulder followed up for
two years, to favorable outcomes of those treated (Bulgen
et al., 1984).

Conflicting results are also reported regarding the

effect of physical therapy treatments.

End! IS the Effect 91 EDXSiQQJ Theranx TIEQIEQDI’
A comparable trial of ice and ultrasonic therapy
demonstrated no significient advantage of one treatment
over the other, as both treatment groups improved in terms
of arm movement and pain relief (Hamer & Kirk, 1976). The
long term prospective study carried out by Binder et al.
(1984a) found that mobilization physical therapy was

associated with a less satisfactory outcome compared to

67
either group receiving local injections, ice, or no
treatment.

Lee, Lee, Haq, Longton, and Wright (1974) compared the
effect of three different treatments with a control group
who received only analgesics. All treatments consisted of
exercises combined with heat, or with hydrocortisone to the
joint, or with hydrocortison to the bicipital tendon. Those
who received analgesics regained least mobility. Among the
other groups there was no difference.

In a study by Bulgen et al. (1984), all patients were
taught pendicular exercises and then divided into four
treatment groups. One group was given intraarticular
steroids, another mobilizations (developed by Maitland),
and a third group ice followed by proprioceptive
neuromuscular facilitation (PNF). The fourth group received
nothing. The treatment lasted for six weeks.

The group that received steroid injections suffered
less from pain and regained mobility faster than the others
during the first three weeks, but at a follow up six months
after the treatment there was no difference with respect to
:mobility between the four groups. The conclusion is that
"there appears to be little place for physiotherapy alone,
and, if used, it should not be continued for more than four
weeks" (Bulgen et al., 1984, p. 360).

Hazleman (1972) assessed the response to treatment in

a retrospective study of 130 patients. The treatments given

 

68
were either steroid injections, physical therapy, or
manipulation under anaesthesia. All patients were also
instructed to perform exercises. No treatment was superior
in reducing total duration of the condition. Physical
therapy was found to exacerbate pain in 28% of the
patients.

One study by Rizk et al. (1983) makes a comparison
between different physical therapy treatments only. The
result is that prolonged pulley traction accompanied by
transcutaneous nerve stimulation gave better results
compared to a combination of heating modalities,
therapeutic exercises, and gentle rhythmic stabilization
manipulation. Mobility was increased in both groups but
range of motion was regained more rapidly in the group that
got pulley traction. The method of treatment with pulley
traction is based on the premise that connective tissue
shows plastic elongation when subjected to mild tension
(Rizk et al., 1983).

To conclude, frozen shoulder is a condition which in
most cases has a spontaneous onset. Pain in the shoulder
region leads to disturbed sleep at night, ordinary
movements with the arm become painful, and the shoulder
becomes stiff. Improvement occurs spontaneously, but the
symptoms can last for up to four years, many times with
permanent, albeit slight, limitation of the shoulder
mobility.

69

In addition, there are conflicting theories as to the
cause of the condition. Histological studies, immunological
examinations, arthroscopy, and arthrography show different
structures to be affected. Regarding therapy, some
researchers argue strongly for manipulation under
anaesthesia, while others are more cautious. Physical
therapy has proven to aggravate pain in some studies.
There is not even one name for the condition but several -
stiff and painful shoulder, frozen shoulder, periarthritis,
capsulitis, adhesive capsulitis. The only consensus that
has been reached is that there is a chronic inflammation of

the joint capsule.

EEEEQEI

The upshot of this review concerning a frozen shoulder
has been to demonstrate how problematic the condition
"idiopatic frozen shoulder" is. It is pnobiemetic fer
., -' ans as ,;e g. - 10 co 'm. r-. -, . . _-r. They
cannot point to any particular reason for the development
of the condition. They cannot guarantee the outcome of any
treatment or that recovery will be complete. However, they
can say with confidence that, given time, functional
mobility will be restored. They can provide medication to
suppress the pain and the inflammatory reaction of the
joint capsule. Finally, they can refer the patient to a

Physical therapist for help in reducing the pain and

7O
regaining mobility eventually faster than if the shoulder
had gone untreated.

Although no studies document how many patients are
being treated by physicians and by physical therapists,
there is cause to assume that most patients are seen in
physical therapy. The reason is that physical therapists
have a variety of physical modalities and therapeutic
techniques to offer, not as a cure but as support during
recovery and an eventual hastening of it.

s o e 's r blema ' o e 's .
Prescriptions never say anything about hurting a patient,

but rather to reduce the patient’s pain. However,

In the non-acute condition there are also
occasions when it may be necessary to hurt our
patients. Examples are many and include
stretching out of shoulder capsules and the
application of transverse frictions. (Paris,
1985, p. 165)

s s m t t' t.
Apart from the pain and the inability to use the arm in a
natural way, it is stressful not to know what caused the
condition, not to know if full mobility of the arm will be
restored or not. Even if it is comforting for health
professionals to inform patients that the condition is
reversible, it is of little comfort to the patients to hear
that this will happen within approximately 30 months

(Reeves, 1975). Besides, any treatment that aims at

71
restoring mobility is, in this case, painful. It is also
unclear to whom or to what progress, or lack of it, should
be attributed once treatment is initiated. Is it the
therapist’s way of delivering treatment, the treatment
technique itself, or the patient’s doings and her ability
to endure pain that causes improvement or not? Or is the
combination of all these factor most important? What is the
role of the talk that the patient and the therapist engage
in?

The literature stresses the psychological value and
impact of the therapist’s communication but excludes the
talk that accompanies any particular treatment. It also
pays minor consideration to the impact of the treatment
technique upon the patient, and the patient’s experiences
of the condition. Those studies that have focused upon the
condition and its clinical treatments eliminate, on the
other hand, the patient’s contribution to the result.

This study focuses upon the everyday practice of
physical therapy. The treatment technique that is being
used, the therapist’s instructions in connection with the
treatment, and what is said about the condition both by the
patient and the therapist have been documented and
analyzed. The following chapter will describe in detail how

this study was carried out.

CHAPTER THREE

THE STUDY: ITS QUESTIONS AND METHODS

Questions of the Study

A micro-ethnographic case study was carried out to
learn more about how physical therapists and patients
approach the problem of frozen shoulder. The patient, who
suffered from frozen shoulder, was followed through her
treatments at an outpatient clinic. The following questions
guided the study: "What constitutes the treatment
situation? What do the patient and the therapist say and do
when working together? What are the social, educational and
interpersonal problems for the therapist and patient to
work out in the therapy sessions? In particular, what makes
a treatment session turn out the way it does? Who do the
patient and the therapist become when working with each
other?"

Treatment situations were documented through
participant observations in fieldnotes, on audiotapes, and
on videotapes. Besides transcribed interviews, documents
such as referrals, the therapist’s evaluations and progress

notes were collected. Considering the importance of the

72

73
patient’s and the therapist’s accounts of what was going
on, the three videotapes were the subject of viewing
sessions and were also analyzed in detail by the
researcher. One of them, a videotape made three weeks
before the series of treatments was over (Video X), was
selected to be reported. Details of its selection are

presented as part of the data analysis.

u ' ' t' o e ud

The first part of the literature review revealed that
few of the models of physical therapy practice that were
given were founded on empirical studies. Rather, various
theories and assumptions about practice were applied to
treatment situations, to highlight certain aspects of
treatment. This approach, in combination with the authors’
experiences as physical therapists, teachers, and
researchers, then led to recommendations for how patient
care should be improved. In spite of the authors’ good
intentions, one can doubt the applicability of the
recommendations since they were based on a particularly
narrow or idealized view of the relationship between the
therapist and the patient which was never questioned.

The tendency to move quickly from certain assumptions
of practice to idealized versions of it should be avoided.
Otherwise one could claim that everything has already been

said about the profession and that all practitioners need

74
to do is to follow the recommendations. But the idealized
versions can easily become norms and if therapists try to
live up to them, they manifest the particular relationship
that presupposed them. The norms might also serve as
criteria against which both patients and therapists can be
judged.

It is therefore important to stay close to naturally
occurring treatment situations and to study them in detail,
to focus upon the therapist’s doings in relation to the
patient’s, to see and to accept that difficult and
confusing episodes arise even in routine sessions, and thus
refrain from categorizing professional practice as either
good or bad. "Back to the things themselves," says Edmund
Husserl, "the primary ‘inventor’ of phenomenology" (Ihde,
1979, p. 15). It is an imperative that must be taken
seriously when the ultimate goal of a study is to gain

insight into what constitutes therapeutic encounters.

W
This study is an attempt to describe, in detail, how
physical therapy sessions, organized around the diagnosis
of frozen shoulder, are carried out. By attending to the
treatment procedure per se, the instructions accompanying
it, the talk between the patient and the therapist, and the
"sounds" of the therapist’s hands and the patient’s arm,

the study shows how different forms of discourse evolve. By

75
analyzing the forms of talk the patient and the therapist
use most frequently, a particular therapeutic relationship
is uncovered.

By paying attention to everyday clinical practice, the
hope is to give a nuanced picture of the patient and the
therapist as they create and sustain a working relationship
that proves to last for a long period of time: to show how
the two make sense of what is happening moment by moment:
and to describe how misunderstandings of each other lead to
episodes of confusion.

The purpose is also to take seriously the patient’s
active participation, both verbal and physical, in the
treatment sessions, particularly since it "looks" as if the
patient’s shoulder simply is manipulated by the therapist.
Thus it will be possible to avoid reducing the patient to
someone who is solely at a disadvantage: to someone who
does not know what goes on in her body: to someone who has
nothing to contribute to the treatment but information

about her medical problem.

eniginal Reeeerch Quescicns

This study is guided by an interest in treatment
situations and a curiosity about what makes sessions turn
out the way they do. Recognizing the role of kinesics and
the centrality of movement in physical therapy encounters,

both talk and movement are focal and are analyzed in detail

76
for information about contextualization cueing and
negotiation of social roles. Three basic questions were
formulated prior to data collection. The fine; one
concerned the fininge of the patient and the therapist. What
do they physically do during treatment? Or more
specifically, how do the patient and her physical injury
and the therapist and the application of a specific
treatment technique affect one another and come to organize
a session in a particular way?

Assuming that any treatment is mediated in part
through talk, the eeccnc basic question focused
specifically on the £213 between the patient and the
therapist. What language is used in a therapeutic setting?
How is this language used? How do the patient and the
therapist talk with one another? What do they talk about?

By looking at the treatment session as a whole and
acknowledging that it is primarily oriented towards a
patient’s physical problem, but assuming that this does not
rule out or exclude the simultaneity of other aspects of
healing, the third question saw the treatment session as an
opportunity for the participants to ventilate concerns
about the medical condition and to learn more about it. It
approached the talk between the patient and the therapist
from a psychological perspective, then from a pedagogical

perspective.

77
s e e nd
W

Apart from these original, basic questions, additional
and more specific questions emerged during the study. The
viewing sessions proved to be highly important in this
respect, but so did the videotapes themselves. The richness
of information each videotaped event contained compelled or
challenged the analyst to apply a variety of questions to
the material itself. After the initial analytic viewings of
the tapes described later on in this chapter were finished,
certain general phenomena became salient. These were first
formulated as strong, simplified assertions, such as, "The
therapist does most of the talking," or "The patient only
moves her arm as long as the therapist has her eyes on
her." The assertions were then rephrased as questions and
thus asked of the material. Regarding the gcinge or
movements of the patient and the therapist, the following

questions were asked:

What treatment technique is being used?

Exactly how is the treatment (the stretching) carried
out?

When is the stretching most effective or when does the
"critical moment" occur?

What is characteristic for the phase when stretching
occurs and for the subsequent phase of recovery?

What should be achieved during treatment and what is
achieved?

How does the session come to be organized around the
specific diagnosis and the specific treatment?

78

With respect to the second basic question, the ccik
between the patient and the therapist is considered
important to study in detail, since inferences can be made
and evidence found for what the patient and the therapist
pay attention to, how they interpret what goes on, and who
they become when working together. The following
assumptions were therefore formulated and tested: The one
who has the floor or takes a turn at talk exerts a certain
amount of control and requires being listened to. The
therapist, who is responsible for carrying out the
treatment, talks most of the time during the phase of
stretching. The patient talks most of the time during the
phase of recovery. Three questions were asked, using some

notions from conversation analysis:

How much time is spent talking and how much time
is spent in silence?

Who has the floor most of the time?

How many turns are uttered by the patient and by the
therapist?

Looking then at the fic;n_nnc_fnnc;icn of the patient’s

and the therapist’s speech, and finding that the patient
and the therapist did talk in different ways at certain

times, the following questions emerged:

What are the patient’s and the therapist’s
primary modes of speaking?

79

What is characteristic for the patient’s and the
therapist’s talk?

Regarding the ccncenc of the talk:

What topics are brought up?

When do different topics come up?

Who brings up which topic?

What does the patient tell about her shoulder?

What theme does the patient keep bringing up and how
does the therapist respond?

How do they talk about what happens during today’s
treatment?

Learning that the therapist was bothered by the

patient "wanting to run the show," om ete ne es ons

arose:

What grounds can the therapist have for perceiving the
patient in this way?

Does the patient do or say anything in particular that
makes the therapist feel this way?

Being also struck by seeing moments in the videotapes
where the patient and the therapist, late in the series of
treatments, seemed uncertain about how to proceed, those

episodes were analyzed in detail. It proved, for instance,

80
that when the patient was ready to work, the therapist kept

on talking and vice versa.

How do such misinterpretations come about?
What causes the confusion?

Why, all of a sudden, do the two misinterpret one
another?

What larger issues do these brief confusing moments
point to?

The last basic question, regarding eche; espects of

neeling, was approached in the following way:

What evidence is there of psychological benefits
for the patient in seeing a physical therapist?

What of the therapist’s doings might be signs of
psychological thinking?

Considering the session as an educational event,
what forms of teaching and learning can be found
at the beginning of the series of treatments and
towards the end?

What instances of "non-learning" can be inferred
from the data and what does this tell about the

patient’s and the therapist’s assumptions
regarding what is important in physical therapy?

Methods of the Study

Ethnographic theories of culture and communication

offer one useful way to proceed to study treatment

81
situations. Erickson, Florio, and Buschman (1980) claim
that.fieldwork methods of ethnographic research are
appropriate when one wants to find out what is happening in
social action in a particular place, what these actions
mean to the people engaged in them, and how the actors are
serving as environments for each other.
Asking what is happening in a specific place is
important for three reasons (Erickson & Wilson, 1982):
First, everyday life (because of its familiarity
and because of its contradictions) is largely
invisible to us--we do not realize the patterns
in it. Second, everyday life is organized in
slightly differing ways from one setting to the
next. Often these objectively small differences
of pattern and meaning can make a big difference
in the subjective reality and qualitative
character of social relations in the setting ...
Third, because many of the pattern are outside of
conscious awareness for the actors in the setting
and because many of the patterns are constructed
around distinctions of meaning attached to slight
differences in amount (such as the measurable
difference between ‘not too loud’ and ‘too

loud’), description and analysis of specific
local details is necessary. (p. 40)

In this study, participant observations along with
fieldnotes, formal and informal interviews, and collection
of documents, that is, traditional methods in the social
sciences (Schatzman & Strauss, 1973), were used to get as
complete a picture as possible of physical therapy
sessions. Several sessions were videotaped or audiotaped.
In addition, three of the vidotapes were looked at with the

patient and the therapist, on separate occasions and not

82
simultaneously, to elicit additional information. These
viewing sessions are discussed under "Viewing Sessions with
the.Participants" in this chapter. Besides, less formal
ways of learning about the two participants occurred during
casual conversations before and after the treatments, over

a cup of coffee or when having lunch together.

0 s' e a

A decision was made early to do an in-depth study of
one patient and one therapist and to follow the two
throughout a course of treatment. This decision was
formulated after having completed a pilot study of physical
therapist-patient interaction at a physical therapy
department located in a hospital (Bk, 1983). That
department served both inpatients and outpatients, and
there was a rapid turnover of patients. Several of the
eleven therapists who worked there worked part-time.
Depending on the time of the day, the same patient might
therefore be treated by one therapist in the morning and
another in the afternoon. The study came to focus more upon
different styles some of the therapists used when working
with patients, irrespective of whether it was the first,
the third, or the last session in a series of treatments
that was observed, rather than providing detailed accounts

of a complete treatment.

83
I chose to study a single therapist experienced in her
field. Assuming that years of professional practice makes a
therapist feel confident about her work, it was hoped that
this would make her less affected by the recording
equipment and my presence, enabling me, in turn, to capture
what I aimed for, namely ordinary or routine treatment

sessions.

c e n

Anticipating that my own previous experience of
working at Swedish outpatient clinics would facilitate my
understanding of how an American outpatient clinic is
organized, I made an appointment with Kathy Davis,1 a
physical therapist at such a clinic, in the summer of 1983.
The purpose was to find out whether Kathy was the
experienced therapist I was looking for and if she would be
interested in allowing me to observe her work with
patients. Kathy had actually worked many years as a
physical therapist, she was the only therapist who worked
at this clinic, and she was willing to be a participant in
the study. The clinic itself was small enough so that
others, like the assistant and the patients, would not be
bothered by my presence. At the time of this inquiry, no

patient was selected.

 

lAll names of people, places, and institutions are pseudonyms.

84
£h212§.21.2§£i§n£

The only criteria for a prospective patient were that
she or he should not suffer from a chronic condition or
disability, that the diagnosis should be common in an
outpatient clinic, and that amounts of treatments were
limited. The diagnosis itself was of minor importance at
this point. No search for a patient had yet taken place
when, in the middle of January 1984, one of the professors “
teaching a class I attended mentioned that she had just
started going to the Medical Center for physical therapy
for her sore shoulder.

Realizing that a prospective patient had presented
herself, I seized the opportunity and asked if I could make
observations and videorecord the remaining treatment
sessions. Dr. Strauss and Kathy Davis agreed, and the data

collection process started.

new

The process of collecting data about the participants
parallels, in this study, that of the patient going to
physical therapy. This means that as a patient one does not
know how many treatments will be needed before recovery is
complete, even if the prescription is restricted to a
certain number of weeks. The patient starts out with an
initial referral that, apart from the diagnosis, prescribes

a treatment and sets a time limit. In this case, the

85
diagnosis is a right frozen shoulder, the physical therapy
services requested are "Hot packs, ROM (range of motion),
massage, ultrasound," the number of treatments to be
carried out are "3 x wk x 4 wks" (Referral, 1/6/84).

If the patient had gotten well in due time, the
treatments would have been terminated after four weeks. But
neither the patient, the therapist, nor the referring
physician was pleased with the result. Progress did occur,
but slowly. A second referral was issued. It stated
"Continue P.T. for 1 month as written. Then call for
further orders" (Referral, 2/10/84). It proved difficult to
predict when the patient would be completely rehabilitated.
The treatments continued without further written referrals
through agreements over the phone. It took almost five
months before the patient had regained close to full
mobility of her shoulder.

The patient made 42 visits to the physical therapy
clinic from January 9 until May 31, 1984 (see Table 3.1).
The first treatment was given by Kathy Davis, the following
three by a male therapist as Kathy had one week’s vacation.
On January 18, 1984 Kathy was back again. The treatments
were given three times per week during January, February,
and March, and twice a week during April. In the first week
of May an attempt was made to give treatment daily for a
full week, but only three of these were carried out. During

the last four weeks of May, the patient was seen only once

86
a week. The recording of the treatments began on January
18 , 1984, the patient’s fifth visit. Out of the remaining
38 visits, 28 were observed. Ten of these treatments were
videotaped, ten were audiotaped and eight were documented
in fieldnotes (see Table 3.1).

Data collection was adapted to what actually happened.
81): sessions were videotaped and two were audiotaped during
the first month of treatments. I had assumed, like the
Patient, that the stipulated time on the first referral was
an indication of when rehabilitation was to be completed.
Later on two sessions were videotaped in March, one in
April, and one in May. After the patient had terminated her
treatments, participant observations were continued
throughout the year of 1984.

My status as a student as well as a licensed physical
therapist made possible particular opportunities to study
bcth the patient and the therapist outside the treatment
sessions. As a student I was able to observe the patient
while attending some of her courses at the university. As a
physical therapist I worked as a substitute during five
weeks in 1984. This occurred after the patient on whom this

s'tudy is focused had terminated her treatments.

87

Table 3.1 Appointment Times and Mode of Recording

W Weeding
12:32 Time
.1/09/84 ? None
1/11/84 ? None
1/13/84 ? None
1/ 16/84 ? None
1/18/84 11:30 AM Videorecording I Study
begins
1/20/84 10:00 AM Videorecording II
1/23/84 01:45 PM Audiorecording
1/25/84 11:00 AM Videorecording III
1/27/84 11:00 AM Videorecording IV
1/30/84 01:00 PM No observations allowed
2/01/84 11:00 AM Videorecording V
2/ 03/84 11:00 AM Videorecording VI
2/ 06/84 02:00 PM Audiorecording
:5 08/84 02:00 PM --
10/84 08:45 AM --
2/ 13/84 01:00 PM Fieldnotes
2/15/84 09:00 PM Fieldnotes
2/ 17/84 Cancelled by P --
2/20/84 Cancelled by P --
2/27/84 01:00 PM Audiorecording
2/29/84 01:00 PM Audiorecording
3/02/84 09:00 AM Videorecording VII
3; 05/84 01:00 PM Audiorecording
07/84 01:00 PM -—
3/09/84 01:00 PM Videorecording VIII
3/12/84 09:00 AM Audiorecording
3/14/84 09:00 AM --
3/ 3.6/84 10:00 AM --
3; 19/84 09:00 AM --
26/84 ? --
3/ 29/84 08:15 AM Audiorecording
4/ 03/84 08:15 AM Audiorecording
4/ 05/84 08:15 AM Fieldnotes
4/ 10/84 08:15 AM Audiorecording
:/ 12/84 08:15 AM Fieldnotes
4;; 5.7/84 08:15 AM Videorecording Ix
9/84 08:15 AM --
g/30/84 Cancelled by T --
s/()1/84 08:00 AM Fieldnotes
s/ 02/84 08:00 AM Audiorecording
S/ 03/84 08:00 AM Videorecording X
8/08/84 08:00 AM --
3/14/84 08:00 AM Fieldnotes
8/22/84 08:00 AM Fieldnotes
/ 31/84 08:00 AM Fieldnotes

88
One viewing session and two brief interviews were also
held with the patient in 1985, and three viewing sessions
with the therapist (see Table 3.2) .

Table 3.2 Date for Viewing Sessions, Videotape
Being Analyzed, and Participant

 

Ease 11.09.918.29 Ween:
03/08/84 V The physical therapist
10/25/84 I The physical therapist
11/01/84 I The physical therapist
11/08/84 X The physical therapist
08/01/85 I The patient

‘

 

The opportunity to serve as a therapist provided
certain insights about how the therapist in the study
looked upon her patients and their predicaments. For
instance, in addition to receiving information about the

patients’ diagnosis I also was informed about "what kind of

people" they were .

28W

When Kathy talked about the patients she categorized
them using three different criteria. One was a rough
d3~agnosis, another was their different scheduling
pI‘eferences, a third was whether patients were demanding or
I“Qt. When the therapist talked about the patients’
diagnoses, they were either labelled "chronic pain

Da‘tzients," "rehab patients," or "sports medicine patients."

89
When she talked about what time of the day the patients
were scheduled, there were "professors from campus" who
came early in the morning, at lunch, or late in the
afternoon. Between 10 and 12 noon and 1 and 2 PM "those on
‘vweajlfare" came. "College kids" showed up between 3 and 4 PM
(Viewing session, 11/1/84) . An average of 13 patients per
day were seen at the physical therapy department. The third
way the therapist talked about the patients was either as
" easy" or "hard." For example, during one viewing session,

the therapist explained that,

The easy patients are the patients that are very
self-motivated. They have a goal in mind already
and all I do is give them the tools to achieve
that goal. Then there are the hard patients, that
don’t have a goal in mind. They suffer. They
don’t see the end yet and they don’t see how to
reach it. And I have to find out, to communicate
well enough with them so I can point those things
out to them.... Those are my hard patients. Well,
there is a major difference. Just look at the
department, sports medicine versus rehab
medicine. Sports medicine is a simple injury.
They can relate to the injury that happened. They
are aware of it. There are no other conflicting
things interfering with the problem they are
having. They know they want to get better and
they know what to do to get better. And here I
am, helping them get better. But with the rehab
patients, other things are involved. (Viewing
session, 11/1/84)

In the therapist’s description of the "easy" patients,
there is no doubt about what was the cause of the injury,
:"<> doubt about the effectiveness of the treatment, no other

problems that interfere with the rehabilitation, and the

90
patients want to get well. They do not question the
't:1:¢eatment the therapist provides. Being athletes, they are
tassted to being told what to do. This might facilitate
following the therapist’ s instructions. However, "easy"

patients can turn into "hard" patients. In the therapist’s

\rjlcsw,

Sometimes they are looking for drugs or they are
addicted or what not to running for example. Then
they turn into hard patients and you have to do
more. You have to teach them about preventive
medicine and it is a little harder for them to
accept. (Viewing session, 11/1/84)

Patients can also be "hard" because it is unclear what

'tllieeir problem really is:

I have to find out what is bothering them, so I
know what I am treating. Whether I am just
treating the back, a plain injury, or whether
there are other things that at least I need to be
aware of. (Viewing session, 11/1/84)

Another group of "hard" patients are those that have other
Opinions of what should be done. Of these the therapist

says,

I want him to do one thing that I know will help
him, which he refuses. He wants to do something
that is not getting him any better.... My
challenge would be to get him to go for what is
best for him. But if he doesn’t want to do that,
there is nothing I can do. (Viewing session,
11/1/84)

 

91
The way the therapist categorizes her patients

<:<>rresponds to the amount and kind of work required of her
‘t:c> treat them. Consideration has to be taken of the injury
the patient suffers from (simple or complex): the cause of
tztaezinjury (known or unknown): eventual other problems that
jgrrterfere with the rehabilitation: the patients’ attitudes
t:c> or understanding of the treatment: and their willingness
t:c> get well. The therapist summarized the discussion in the
15c>llowing way: "Betty (the assistant) and I like a couple
()1? sports medicine patients in between our hard patients,
lbeeceuse they are easy and they are very positive" (Viewing

assession, 11/1/84).

I] E !' ! . ll 5! 2
Dr. Strauss, the woman who in this study is being
treated for a painful shoulder, belongs to the category
"hard" patients (Viewing session, 3/8/84). This is
dllscussed in detail in the section "Viewing Sessions with
the Participants" in this chapter. Dr. Strauss reports her

sl’lnptoms as follows in an early interview:

Actually almost a year ago (January) I began to
have pain in my right shoulder when I carried my
briefcase.... It must have been around May, there
was sort of a cold wet spell, I noticed when I
woke up in the morning my right arm would hurt.
But I couldn’t figure out why, I hadn’t done
anything to injure it. And I thought it would get
better by itself, but by, I would say June, I
could no longer lift my arm up like when you rest
it on a car window. I couldn’t lift it like that.

Iifcaaxr

Said

92

Or I couldn’t lean on it on a table having lunch.

By that time, I was less and less able to lift my arm
or use it at all and it was very stiff. There

seemed to be no cause whatsoever for my shoulder

to hurt and not get better....

I am also left handed so I don’t use my right arm very
much and it just seemed like it got that way all by
itself.... There was certainly no reason to wake up in
the morning and find my arm hurting.

For a while it was hurting all the time so that my
whole right side, upper right quadrant was painful and
ached. My whole shoulder ached, muscles, this muscle
bundle here between my shoulder and my neck was
painful....

I probably did it to myself by not moving it. But
the more it hurt, the more I didn’t use it and
the more I didn’t use it, the worse it got and so
on. Now I am all frozen up and I must have done
it to myself.... Well, I’m not responsible for
initiating it, but maybe for the frozen part of
it, from just not using it. (Interview with the
patient, 1/20/84)

This description is reiterated in a viewing session a
after the treatment was finished, when the patient

the following:

All I knew was that it her; and I couldn’t dc
anything. And I couldn’t eleep at night. Then you
wake up and you’re EIIQQ and then you still have
to kind of plod on with your day.... I couldn’t
lift it, I couldn’t turn it, I couldn’t pull it
over this way (across the chest). (Viewing
session, 8/1/85)

Dr. Strauss’ description of how the problem started,

it‘cmw "unbelievable" it was to get severe pain without a

93
known cause of it, how restricted the use of her arm was,
is typical for an idiopathic frozen shoulder. What also
puzzles her is whether she herself might have caused "the
frozen part" of it, something never intended.

Dr. Strauss is a 50-year-old woman. She was born in
Kansas, but has lived the last 13 years in Lindesberg. She
is a social scientist and holds a position as a full
professor at the university. Before going into academics,
Dr. Strauss worked as a lab technician.

Dr. Strauss had been referred to the Medical Center by
her primary care physician, Dr. Brown. Originally the
diagnosis was tendinitis of m. supraspinatus, for which
Shots were given. The pain ceased only temporarily.
Physical therapy treatment at a local hospital in November
1983 helped initially, but after one session pain increased
tremendously and Dr. Strauss never went back to that clinic
(Video I, 1/18/84) . Troubled by the gradual worsening of

her shoulder pain, Dr. Strauss had gone through several
e1 inical examinations in order to find out why the problem
Occurred. A car accident in 1979 could potentially have
acne some damage to her neck. Insurance covered all the
e>€penses for medical matters eventually related to the
heczident. X-rays were taken of her neck, an EMG was carried
Qut, and an appointment with a neurosurgeon was made to

Qiscuss the findings. Dr. Strauss reported these findings

94
to the therapist during an early therapy session as

follows:

There are posterior and anterior osteophytes on
the fifth and sixth cervical vertebrae, a central
osteophyte in the fifth vertebrae and a defect in
the area of the fifth vertabrae. That’s from the
myelogram. So she (Dr. Brown) said then that it
was one of those things pushing on the spinal
cord. Must be the central one. I don’t know. She
(Dr. Brown) said it (the EMG) was abnormal but
not specifically abnormal. Anyway I didn’t have
all the symptoms that she would expect, if the
nerve was entrapped.

What she (another physician) said in the hospital
was that there was a large spur pushing on the
spinal cord and that she thought it ought to come
off. That’s why they sent me to the neurosurgeon
and then he said he didn’t think, that he thought
that might or might not bring relief. So he and

Dr. Hall and Dr. Brown decided to be
conservative. (Video I, 1/18/84)

The conservative treatment was to try physical therapy
zigzain and in January 1984 Dr. Strauss started seeing Kathy

IDatvis, registered physical therapist, at the Medical

center.

1] El . J Tl l ! . !l E! 3
Kathy Davis is 40 years old. She was born in Europe,
where she also received a bachelor of science degree in
physical therapy. However, she never practiced her
pZI'—"<:>fession while in Europe. She moved to the United States
2 0

years ago and she has worked as a physical therapist for

‘t:}he last 12 years. Before accepting her present position at

95

the Medical Center, she worked for six years at a pain
clinic in a hospital in Hallsberg. since the opening of the
physical therapy unit at the Medical Center in 1983, Kathy
Davis has been the only physical therapist working there.
To help her she has an assistant.

Dr. Strauss and Kathy Davis live very close to each
other north of the university campus, but had never met

until the treatments started.

Ine Medical Cence;
A market study of the Medical Center (Health Systems,
:1984) reports the following. The Medical Center opened in
21976. It is located in Lindesberg between major freeways,
.krut.on a low traffic road. It was designed for two
IPIIrposes. One, to provide complete outpatient health care
Eseervices the general public, the university faculty, and
‘lee staff. Two, to serve as a clinical setting for the
Inedical programs at the university. The Medical Center
offers eleven different major programs and is staffed by
both allopathic and osteopathic physicians.
The Health Institute (HI) is one of the programs. It,
45%?! turn, consists of two separate clinical entities. One
sE>ecializes in sports injuries, the other in medical
3‘?<!habilitation. The physical therapy unit is part of the

rehabilitation program.

96

Written referrals are the rule. Patients are referred

not only by physicians working within the Health Institute
but also by others. Most of the patients who visited the
Medical Center in the fiscal year of 1983 were employed by
the university in Lindesberg: the state government, located
in the capital Hallsberg: and the car plant also located in

Hallsberg (source: Medical Center Administration, Dec.

1983).

The_Bursical_1beraex_§etfing

The physical therapy localities consist of one large

t:reatment area, a storage room, a room with a whirlpool,

sand an office. At the center of the treatment area there is

is..large table with a mat on it (see Figure 3.1). Next to it
1:11ere are weights, dumbbells, wristbells, and anklebells
£31tored on a small table. Some of the weights are to be used
CD!) the N-K table, which is placed against a wall. This is
uSed for strengthening of the major leg muscles. Along one
‘Pviiill there are parallel bars, a three way mirror, and a set

of wall pulleys. On another there is a graded staircase and

next to it a stationary bike.
Curtains separate three cubicles from the rest of the
large treatment area. In two of the cubicles there are, in
each, an adjustable treatment table, a cabinet, a sink, an
ultrasound machine, a chair for the patient, and hangers

for clothes. In the third cubicle there are traction

97

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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TABLE
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Figure 3.1 Treatment Area, Physical Therapy Unit

98

equipment, a traction table, a muscle stimulator, a

cabinet, a chair, and containers for hot packs and cold

packs.
Dr. Strauss is always treated in one of the cubicles.

Before Kathy goes to the waiting room to get her patient,
she covers the treatment table with a white sheet and

adjusts the pillow. She places a white gown on the table

for the patient to change into.
When the treatment is over, Dr. Strauss frequently
stops outside of the treatment cubicles where a smaller
lpiece of equipment is hanging on the edge of a wall. It is
Inade of wood, has the shape of a ladder, and is
zapproximately 25 inches long and two inches wide. Each
"step" is numbered. Facing the ladder, she climbs the
ladder with her fingers until she reaches as far up as
I?c>ssible. This provides an easy way for the patient to do
liter own evaluation, to get a sense of her progress. The
l=<esults were never written in the therapist’s progress

3'1<>tes, but are frequently referred to in my fieldnotes (see

AI>pendix A) .

C es

Treatment situations are very complex. Roughly, one
<=iin.say that they involve two people, a diagnosis, 8
i‘llbeatment technique, and a location. The complexity lies in

<3<Jordinating the actions that are hidden in the words

99
"treat" and "being treated." As those words are associated
with the roles of a therapist and a patient, the division
of labor is already allocated. Granted, the therapist
"delivers" treatment and the patient "receives" it. But
that does not mean that the therapist is the active one and
the patient the passive. Both are active, but in different
ways.

Goffman defines (1959) face to face interaction as

"the reciprocal influence of individuals upon one another’s
actions when in one another’s immediate physical presence"
(p. 26). He stresses that the two are interdependent. What
cane says or does cannot be understood separately from what
the other says or does. Neither can the location in which
the encounter takes place be excluded. Both participants
make sense of each other’ 8 actions and define the situation
Elczcordingly. Merleau-Ponty (1962, p. XVIII) says "... there
is not a human word, not a gesture, even one which is the
<>11tcome of habit or absent-mindedness, which has not some
meaning."

The influence of phenomenology on sociology and
EIratlu'opology is subsequently to be seen in studies that are
‘c=<>ncerned with "constituted human meanings" (Ihde, 1979, p.
14 3) . Interpretive research, as one form of educational
13?€3search, emphasizes the necessity of studying how people
I“Elke sense in order to understand why people act as they

'cith. The object of interpretative reserach is action, not

100
behavior. Action is defined as "the physical behavior plus
the meaning interpretations held by the actor and those
with whom the actor is engaged in interaction" (Erickson,

1986b, p. 35). Besides,

Humans, the interpretive perspective asserts,
create meaningful interpretations of the physical
and behavioral objects that surround them in the
environment. We take action toward the objects
that surround us in the light of our
interpretations of meaningfulness. Those
interpretations, once made, we take as real -
actual qualities of the objects we perceive.
(Erickson, 1986b, p. 34)

Erickson talks about the world as a world of
<30mmunication. Contrasted to the Newtonian world where
lehysical objects have form, mass, energy and velocity, in
the world of communication there are no such substances.
ltlastead there are messages and information, with
illaformation residing inside each event, each object. This
"lpropositional or informational aspect of the events and

<>lajects in the natural world" is the theme in cybernetics
(Olgaard, 1983, p. 27).

Bateson (1972) has elaborated extensively upon this in
3tlfiLS'work. Notably in his theory of communication he claims
‘ZJIat all behavior is communicative. Verbal communication
<=E1nnot be considered more important than non-verbal

Communication, for instance.

101

To find out how and in which ways a therapist and a
patient communicate with each other, to find out how they
cooperate in creating any treatment, accurate records of
treatment situations must be obtained. Videorecordings are
to be preferred (Erickson, 1982: Kendon, 1979). Thereupon,
analysis and interpretation of what is captured on the
videotapes must take place.

Through videorecordings one is able to capture details
of events as they occur naturally at a particular time, in
a particular setting. The data are highly sensitive and

stored permanently. As Duncan (1982) says,

The speed and multiplicity of actions occurring
in interaction require that some sort of
permanent record--film or videotape-~be used for
research. Such a record permits fine-grained,
accurate observations of any set of observable
actions (taking up one type of action at a time),
while preserving in the transcription the
sequence in which the actions occur. Using film
or videotape one can review the interaction as
many times as required--and in slow motion, if
desired--to verify and correct one’s
observations, and to add new observations, if
desired. It is obvious that any sort of real-
time observing process cannot begin to provide
comparable scope and accuracy. (p. 177)

Erickson and Wilson (1982) state that documentation in
‘tlae form of videotapes is especially appropriate to the
study of "the conduct and organization of face to face

interaction" (p. 40). They go on to say that,

102
Audiovisual documentation and analysis is also

useful in discovering new insights about the

organization of everyday life in educational
settings--new perspectives on phenomena that may

have been overlooked because of their subtlety
and their familiarity to those closest to them.

(1982, p.41)

Although Erickson and Wilson refer to the study of

classroom interaction, what they argue for can be

generalized to other settings.

H2u_the_yide2tapes_flere_uade

Initial contact had been made with the patient and the
‘therapist prior to making the first videotape. Both of them
Imere carefully informed about the purpose of the study, how
the sessions were to be recorded, and how the videotapes
Were to be used. They were reminded of their right to
refrain from participating in the study at any time and/or
1:<3 have certain episodes erased from the videotape, if they
53:: wished. The director of the rehabilitation program had

approved the study. Consent forms were signed by those

involved (see Appendices B, C and D).
Following the recommendations by Erickson and Wilson

(CJL982) about the most unselective visual recording, the
<2eamera was set up on a tripod in the booth where the
"=Jreatment took place. A wide angle lens was used. The
ItIicrophone was placed next to or on the treatment table. No

‘3lJecial lighting was used. The camera ran continuously and

103
the angle was adjusted only to make sure the participants
remained within the visual frame.

The decisions regarding what to tape, where to place
the camera, when to start and when to stop taping, were all
made by the researcher. The goal was to get as much as
possible from the participants within the frame--to start
the taping before any of them had entered and not to stop
until they had left. By this means the researcher refrained
from being the one who determined "this is the moment when
the treatment starts and now it stops." From the
participants’ point of view the treatment could have
started earlier or later. The participants’ perceived
beginnings and endings are indications of their
interpretation of what is going on, of what context is now,
and these are crucial data or information in this kind of
research.

In some videorecordings, where the whole session
included the application of hot packs (20 min.), the
ultrasound treatment (10 min.), and the manual treatment
(20-25 min.), the camera was turned off when it became
obvious that the therapist was going to stay out of the
booth for a longer period of time. This would occur after
the hot packs had been applied and no other treatment was
to be given at the same time. After setting up the
equipment, I remained in the booth to take fieldnotes. I

‘would leave the booth temporarily.

104

During the last two videorecordings I set up the
equipment, left the booth, and returned temporarily to
check the camera angle. In the meantime I helped the
assistant with various tasks.

This brings up the issue of how my presence and the
presence of the camera affected the behavior of the patient
and the therapist. This problem can probably never be
resolved. Since various ways of documenting the treatment
sessions were used (see Table 3.1), I can say that those
that were videotaped do not differ from those observed at
other times.

Some evidence that the participants acted as they
usually did became apparent during the second week of the
study. After having completed the fourth videotape
(1/27/84), I asked Kathy if the taping bothered her. "It
wasn’t such a problem," she responded, except that she
wanted to be alone with the patient the next session, to
see if she would be more relaxed. "She is so tense." She
[the therapist] didn’t know if it depended on me being
around or if it was the pain (Fieldnotes, 1/27/84). I
'called Kathy (1/31/84) to see what had happened. Kathy
answered "It was the same. Unchanged. So you can come next
time if you want to. She behaved in the same way. She cried
a little bit. But she is getting better, slowly"

(Fieldnotes, 1/31/84). Thus observations were resumed.

105

During the following Videorecording (2/1/84), Dr.
Strauss and Kathy discussed my presence. Dr. Strauss said
it doesn’t bother her "when she sits here" and Kathy said
"I get so tangled up in your shoulder here" (Videotape V,
2/1/84).

Other evidence comes from discussion with the
participants. Both claimed they felt slightly ill at ease
at the beginning of each recording, then more or less .
forgot about the camera.

Erickson and Shultz (1982) state that,

While immersed in doing, one does not regard
one’s actions from the point of view of a
detached observer.... In lived time, the
compelling power of everyday life is that people
become absorbed in it and take its ‘reality’ for
granted. (p.56)

The prescribed treatment has to be carried out in
actual therapy sessions. The therapist has to give the
ultrasound, apply the hot packs properly, and instruct the
patient to perform certain movements. The patient in turn
has to make the treatment possible, by doing what is asked
of her. Besides, both of them are occupied with talking and
listening. All this demands their attention. For the
researcher this is an opportunity to describe and analyze
actual treatment situations, rather than role-plays, for

the purpose of theorizing about practice.

106
ss 3

When doing ethnographic research the goal is not only
to describe the ongoing activities as accurately as
possible but to capture how the participants themselves
look upon the same activities. Through this dual approach
one arrives at both the outsider’s and the insider’s
perspective. In order to elicit the participants’
perception of or opinion about some aspect of the
treatment, they were invited, separately, to viewing
sessions (see Table 3.2).

The use of videotaped material as a means of
elicitation is described by Florio (1978) and Erickson and
Shultz (1982). A viewing session, conducted as described
below, provides an opportunity for and encourages the
informant to bring up issues that are of significance to
her. On purpose, the researcher refrains initially from
asking questions to avoid influencing or directing the
informant. Each informant, in this study, was simply asked
to turn off the tape when something interesting or unusual
happened. Or, if the informant just felt like making some
comments about something on the tape, it was turned off.
The comments the informant made, and the discussion that it
led to, usually led to a more fine-grained inquiry about
what made the informant stop the tape. It could also result
in an analysis of a particular situation in the tape. These

viewing sessions were audiotaped and later transcribed.

107

Through the viewing sessions the informant helps the
researcher to pay attention to particular episodes. For
example, on March 8, 1984 the therapist and I looked at the
fifth videotape, recorded on February 1. At one point the
therapist turned off the tape and commented on the
patient’s attempt to be in or take control. The patient had
asked the therapist to wait a few seconds before she would

bring the arm up further. The therapist said,

But the way she did it to me. Like she wanted to
control the whole treatment program. And I want
the control back, ya. If it is what is going to
happen next time, I don’t know what I am going to
do. But somehow or another she cannot run the
show. (Viewing session, 3/8/84)

In this way the therapist guided the session to
looking at moments where there was some kind of dissonance
or disagreement, between the patient and the therapist.

By paying close attention to moments of conflict, the
rules that otherwise guide the interaction and that now
have been violated, can be made visible. This is one way of
learning about what organizes smooth interaction.

The first viewing session is of importance in the
study because of what was brought up. The intensity with
which the therapist talked about the patient was striking.
Besides, I had considered Dr. Strauss an ideal patient. She
attended almost every scheduled session (see Table 3.1).

She endured the pain during the treatment. She did the

108
recommended exercises. Being used to a regular exercise
program since her car accident, Dr. Strauss just added the
exercises for her shoulder. In class she placed her arm on
the back of a chair to stretch it passively. She struggled
with using her right arm as much as possible when taking
her coat on and off. But the therapist was referring to
something else. More attention was therefore given to how
the patient and the therapist worked together to accomplish
the treatment and to the fact that this was difficult. It
proved that the therapist could not simply carry out what
"the doctor ordered," but needed the cooperation of the

patient at every step of the treatment.

2W

As stated in chapter one, this study is based on
phenomenological thinking. It has had implications for the
methods that have been used, the way transcriptions have
been carried out, and the analysis of the data. Apart from
following the pragmatic advice by Erickson and Shultz
(1981), as described below, an attempt was also made to
stay close to the steps outlined by Ihde (1979) regarding
inquiry in a phenomenological tradition.

These rules state, first, that phenomena are to be
attended to as they appear. Second, they shall be
described, not explained. Third, all phenomena shall

initially be equalized, that is, no assumption is to be

109
made about any hierarchy among them. This so called epccne
"requires that looking precede judgment and that judgment
of what is ‘real’ or ‘most real’ be suspended until all
evidence (or at least sufficient evidence) is in" (Ihde,
1979, p. 36).

The fourth rule, which represents another level of the
investigation, urges one to look not at the particularities
of phenomena, but at the essences of them or their
essential features. Any pattern that is repeated is
considered significant and must be actively examined.

As mentioned at the beginning of this chapter,
material was collected through different approaches,
including participant observations, interviews,
audiorecordings, videorecordings, and viewing sessions. The
material or the raw data appear either immediately in
written form, like the fieldnotes, or in the form of sound
recordings or videorecordings. These recordings had to be
transcribed before they could be analyzed as texts too.
Since the emphasis in this study is upon the videotapes,
details of how the work proceeded to transform pictures
into words will be described. It is important to mention
beforehand, that every transition from picture to text,
from spoken language to written words, inevitably includes
both a reduction of the raw material and a reconstruction

of it. In addition, the amount of detail of behavior that

110
each taped event contains requires repeated viewings nefone

any form of transcription is even attempted.

t'c V ew' s o s

The viewings of the tapes can be performed
differently. A complete tape can be viewed several times,
or in small segments. The sound can be turned on or off.
One can listen to the sound and then look at what has
happened or reverse the order.

Empirical studies, reviewed by Erickson and Shultz
(1981), have demonstrated that people in face to face
situations organize their behavior into segments or
"chunks," called principal parts or contexts. The junctures
between these are constituted by postural reorientations by
the participants. The new postural configurations or
positions are then sustained during the following segment.
Assuming these shifts to be of importance in the study of
interaction, Erickson and Shultz (1981) developed a six-
stage model for how to view videotapes analytically. The
model is also an example of how to reduce the amount of
data. It was used in the study as follows.

First the tapes were indexed according to the major
occasions they contained, Stage 1. Four to five different
segments were identified. Ultrasound was given: hot packs
were applied: a manual treatment was administered: the

patient was instructed to move her arms while using a wand:

111
and/or the patient was asked to do some strengthening
exercises with a barbell.

At Stage 2, a decision had to be made regarding which
of these segments to focus upon. So, the same tapes were
viewed again, searching for one segment or event that was
similar in the tapes. Out of the four to five segments,
only the ultrasound treatment and the manual treatment were
given from the first until the last session. Of these two,
the manual treatment itself demonstrated most clearly what
is characteristic for physical therapy practice and was
thus selected for further analysis.

When this decision was made, and anticipating many
hours of viewing, copies were made to avoid working from
the originals. At the same time a time-generator was used,
so that digital clock numbers were printed on the screen.
The viewing was now restricted to the segment containing
the manual treatment but extended to what happened right
before and after it. The indexing procedure was repeated,
now facilitated by using the time on the screen. At each
viewing, notes were taken of what was happening. Then this
information was condensed onto a chart along a horizontal
time line. It proved that two phases alternated
continuously, a hands-on and a hands-off phase, to be
described in Chapter 4.

At this point, Erickson and Shultz suggest informants

'be invited for viewing sessions. Here the study departs

112
from the model. The intense data collection process did not
allow time for the kind of preliminary analysis called for
by the model. The patient and the therapist were both
working full time, and could not set aside time for viewing
sessions. However, one viewing session was held while the
study was being carried out. On March 8, 1984, the whole of
videotape V (2/1/84) was viewed with the therapist. The
impact of this single viewing session on the formulation of
the research questions and analysis of the data is
discussed in this chapter under the headings "Viewing
Sessions with the Participants" and "Analysis of
Transcriptions." The other four viewing sessions were
carried out after the treatments were over (see Table 3.2)
when it was feasible for the patient and for the therapist.

Returning to Stage 3 of the analytic viewings of the
tapes, the viewing now focused on behavioral details during
both the two phases and the transitions between them.

At Stage 4 this whole segment, that is, the manual
treatment with all its hands-on and hands-off phases, was
built into a preliminary model of the structure of the
treatment session. This particular procedure is called a
"type-case analysis" by Gumperz (Erickson & Shultz, 1981,
p.156).

In Stage 5 this "type-case" was tested for its
validity by looking for four types of evidence, including

the following (Erickson & Shultz, 1981, pp.156-157):

113

During those moments the model designates as
moments of transition there are descriptively
specifiable shifts in interactional performance
occurring.

After a moment of transition, specific forms and
functions of communication behavior--ways of
listening, ways of speaking, kinds of topics,
speech acts, postural positions, etc.--are
differently distributed in contrast to their
frequency of presence or absence and their
sequential position of occurrence during the time
prior to the moment designated by the model as a
moment of transition.

After the moment of transition, kinds of
interactional behavior which before the juncture
were sanctioned if present (or absent) are no
longer sanctioned by participants if these
behaviors are present (or absent), and kinds of
behavior previously not sanctioned are now
sanctioned: i.e. participants behave as if rules
of appropriateness differ from before the
juncture to after it....

If in a viewing session the participants
themselves or other informants are shown the
juncture and its immediate surround, their
accounts of what is socially appropriate before
and after the juncture will agree with

analytically descriptive evidence of types 2 and
3 above.

The last stage involves a test of this model for its
generalizability. The selected tapes are looked through
again, to see if the model or "type-case" is representative
or not. If so, the generalizability is confirmed, at least
within the data available. The manual treatment that is
analyzed and reported in this thesis is considered typical

for a type-case analysis (see Appendix E).

114
I . !'

As a result of the analytic viewings described above,
the synoptic chart and the details of the type-case model
serve as rough descriptions of what has taken place. The
next step is to transcribe carefully what the participants
say and do.

Although the researcher’s goal is to make verbatim
transcriptions, to be as clear as possible when describing
what the participants do and how they move, each
"transcription is a selective process reflecting
theoretical goals and definitions" (Ochs, 1979, p.44). In
this study, for analytical purposes, two parallel
transcriptions have been made. One is the transcription of
what is uttered, be it words or sounds (see Appendix F).
The other builds upon the first one and adds the non-verbal
or non-vocal communication that takes place (Appendix G).
Time has been noted on both of these transcriptions, but is

only shown here in Appendix G. Stubbs (1983) stresses that,

much of the complexity of spoken conversation is
evident only in close EIIELQD transcriptions...
such as false starts, hesitations, self-
corrections, ungrammatical and unfinished
sentences, overlapping utterances. (p. 228)

He adds, "Conversation looks odd, incoherent and broken
‘when seen in the written medium - but it does not ecnnc odd

'to those taking part in it" (p. 228).

115

In the first transcription special attention has been
paid to changes in prosody, on the assumption that some of
the meaning of an utterance is to be found in the way it is
said. The transcription of the speech is primarily based
upon a copy of the sound from the Videorecording. After
having spent several hours listening, going back to the
videotape and listening to the sound there, speech and
other paralinguistic phenomena and sounds have been written
down.

The symbols that are used are modifications after
Bennett (1982). What is inaudible is marked with a line.
Words that are emphasized are underlined: elongation of
vowels are represented by colons: overlapping speech is
placed within brackets. Intonation is marked above the word
with a falling or rising arch, as in the following example,
where the therapist says: "Let me get it out to the side Is
that painffii At that p155: You do better at this 55;;
(Video X, 5/3/84).

As natural speech seldom benefits from being analyzed
as sequences of sentences, Goffman uses the term
"utterance" (1981, p.22) to refer to the spoken word. This
way of thinking about an utterance as a turn or a turn at
talk has been adopted in this study but also extended to
include whatever sound is heard by the researcher. Every
word, deep exhalation, and sigh has been classified as a

turn. Trager (1964) labels the noises that do not have the

116
structure of language for vocalizations. The combination of
these vocalizations and the "voice qualities" of pitch,
rhythm, and tempo are called "paralanguage" (Trager, 1964,
p. 275). An audible exhalation by a patient in a treatment
situation many times is a profound statement. It needs to
be taken into account when the talk between a patient and a
therapist is focused upon. So "P exhales (6 s)" is one
turn, as well as "T: Kee::p going Kee::p reaching."
Focusing the listening on the prosody of the uttered words
and sounds led to the realization that each party uttered
several short phrases, more or less complete sentences, or
many imperatives within the same turn at talk. The content
of these sub-units could be different as well as similar.
Or the topic could be changed within one turn.

Each sub-unit represents a tone-group or breath-
group. Most of the time these breath-groups coincide with
the specific function of the utterance itself, such as
"Move it back That’s good." Other times they don’t, as in
"Good and relax." The sub-units are therefore called
functional units. Another term might be "move" (Coulthard,
1977). The identification of the first word of each
functional unit (marked with a capital letter, except "I")
has been arrived at through intensive listening and a
search for distinctions between pronounciation of words.
“The example "T: I won’t push any more Try to relax Your

aribcage Your other shoulder" contains four units, each of

117
them with different content but similar prosody. This
classification has then served as the basis for tallying
the number of functional units.

Silence has been marked with one period per second up
to five seconds. More than five seconds have been marked
within parenthesis, such as (6 3). To uncover how people
speak and to refrain, initially, from one’s own inclination
to fill out incomplete sentences, instead of "accepting"
them as they are, conventional symbols such as period,
comma etc. have been excluded.

To visualize the continuity of the conversations and
to avoid giving the impression that each turn that starts
on the left margin is an introduction to a new conversation
or another topic (Ochs, 1979), each turn has graphically
been placed in connection to the preceding one, but on the

line below, as in the following excerpt:

T: Yeah That really looks better thanlwhen we
P: Yeah

started out Let me get it out to the side Is

that painful At that place You do better at

this one
P: Yeah ((exhales))
T: Okay
P: It hurts right in
here
T: Okay Okay Go push (6 3) Give it a real hard
push ... .. Good and relax.(Hands-on VI,

Forward flexion, Video X, 5/3/84).

In the latter transcription several additional

features have been noted. They include facial expressions;

118
direction of gaze, sometimes inferred by head position:
gestures that accompany speech: movements with, for
instance, an arm or the whole body: small changes in
posture, like slumping or stretching a back, or gross
changes like leaning forward or backward, that is, all that
affects the distance between the participants.

A transcription system as described above is of
advantage to the analyst who has listened to the speech
repeatedly, who has an audible memory of the voices that
appear on the tape, and who actually hears them when
reading the transcribed versions. The same transcription
can, however, mislead or cause misunderstanding for the
novice reader of it.

Knowing also that any presentation of transcriptions
can have an alienating effect upon the reader (Stubbs,

1983), minor mcdifications have been made wnenever nnrases

' o e rom nsc ' d
yidecreccrced_eeeeicne. The original transcription system
remains unchanged in Appendices F, G and H.

While still maintaining the demarcation of breath-
groups (or functional units) and assuming the verbatim
phrases are to be read like a script, a question mark (?)
will be added to symbolize rising intonation and a period
(.) to symbolize falling intonation. Both of them thus
indicate the end of a breath-group. To separate the period

that will now be used to mark the end of a breathgroup from

119

the periods that were used to mark each second of silence,
seconds of silence will now be placed within brackets, as
in [...] and [10 s]. As a rising intonation at the end of
an utterance can be interpreted as a request for
information or confirmation ("Wanna have it back?"), but
also can occur in a happy exclamation ("Good stretch hm?"),
this is addressed throughout the text.

The excerpt on page 117 will have the following
appearance after it has been adapted to be read like a

script:

T: Yeah. That really looks better than when we
P: eah.
started out. Let me get it out to the side. Is
that painful? At that place? You do better at
this one?
P: Yeah. ((exhales))
T: Okay.
P: It hurts right in

here.

T: Okay. Okay. Go push. [6 5] Give it a real
hard push. [...] [..] Good and relax.
(Hands-on VI, Forward flexion, Video X, 5/3/84)

 

The value of working from double transcriptions, where
one contains only words, sounds, and time when nothing is
said, and the other includes kinesic behavior and
descriptions of the movements that occur during the time of
silence, is, among other things, that it makes the analyst
aware of different forms of interaction. It also allows for
thorough exploration of the material. This is exemplified

in the next section.

120
E J i E ll T s . !'

As this is an explorative study, the transcriptions
and the original videorecordings have been analyzed in
several ways. The first transcription has been used
primarily in determining the time allotted to the different
phases: the time allotted to talk and silence: the number
of turns and functional units: the categorization of the
patient’s and the therapist’s talk (form as well as
function): the topics that are brought up. The second
transcription, which in no way has replaced the
videorecordings, has been used in the analysis of the
phases of stretching and the phases of recovery. The second
transcription has also been used when determining who
initiates versus terminates each phase of stretching and
when locating and describing the episodes of confusion.

Thus, certain notions from conversation analysis
(Sacks, Schegloff, & Jefferson, 1974) such as turns,
functional units or moves, coherence in conversations, and
adjacency pairs have been applied in the analysis. The
content of the talk has been analyzed from several
perspectives, and a context analysis has also been carried
out.

For instance, when attending to coherence in the
conversations between the patient and the therapist, notes
were taken of those instances where it was lacking. For

example, a question by the therapist, "Is it tender

121
there?", seemed to have no connection with what had been
talked about previously or what followed it. By turning to
the videotape the phrase was found to be an "answer" or a
confirmation of what the therapist had perceived the
patient to have said non-verbally. The patient had placed
her left hand over her right shoulder, while at the same
time wrinkling her eyebrows, indicating discomfort.

Then, looking at the tape as a whole, it proved that
this phrase by the therapist, which she did not immediately
follow up on, had consequences. It led to several
interactional difficulties later on in the treatment. This
will be discussed in chapter five.

As described previously, the therapist in the first
viewing session chose to talk about an instance where she
perceived the patient to be wanting to "run the show." In
another viewing session (11/8/84) she pointed out that the
patient was not ready to start a new attempt of stretching
at the same time as she was. Both instances are examples of
moments where the two of them had been unable to reach
consensus. They "missed" each other, as they defined the
ongoing situation differently. On one level they displayed
differences in opinions, on another they did not coordinate
their movements well.

In the last viewing session the therapist also
discovered, to her own surprise, that she could "do

nothing" if the patient was not ready (Viewing session,

122
11/8/84). She thus indicated difficulties with transitions
from one phase to another. Those moments where the
therapist placed her hands upon the patient’s arm and when
she removed them had been considered from the beginning to
be significant moments in the treatment. I had assumed that
these instances would give valuable insight into how the
patient and the therapist coordinated their talk and
behavior. However, now it proved that not only were these
transitions indeed troublesome, but that it was of little
value to isolate them from the rest of the treatment. The
significance of them was lost once the context in which
they occurred was removed. Instead, all of what happened
during the manual treatment on three different occasions

has been analyzed, more or less in detail.

Videotapes Selected for Detailed Analysis

The videotapes used in this study are numbered I, V,
and X. They were selected primarily because they had been
used in viewing sessions (see Table 3.2). Also, they
represent different points in time in the series of
treatments. Although of good quality, small portions of the
talk of the Videorecorded sessions have not been possible
to transcribe either because the participants spoke in low

voices or the sound from a patient using the stationary

123
bike or another patient talking to the assistant was being
recorded instead.

The last Videorecorded treatment (Video X, 5/3/84),
which was followed by another four sessions before the
patient stopped going to therapy, was chosen to represent a
type-case of the manual treatment and appears therefore in
chapters four, five, and six. The reason behind this
decision is that one assumes that interactional
difficulties might occur in the beginning of a series of
treatments when the participants do not know each other:
the treatment is new to the patient: the therapist is
uncertain of the patient’s response or reaction to the
treatment and she does not know how much pain or discomfort
the patient can tolerate. Also, it is unclear at which
stage of the frozen shoulder a patient is, as discussed in
chapter two. Is is the stage where pain or stiffness
dominates, or has the recovery period started? By now,
after four months of treatment, the patient and the
therapist know each other. They have established a routine
that is familiar to both of them. The treatment or rather
the stretching is the same. The patient is now in the
"recovery phase" (Reeves, 1975). Compared to when
treatments started in January, all that varies is the daily
condition of the shoulder. Thus there is little reason to
believe that the treatment should not run smoothly. In

addition, the actual, physical outcome of treatments is

124

always of interest to professionals in the field, and in
this session the therapist and the patient find that they
have "actually hit home," that is, the patient has gained
full forward flexion (Video X, 5/3/84). This is, however,
not mentioned in the therapist’s progress notes, which
state "5/3/84 Same as above (ultrasound and stretching).
Pain today. Signature."

With data from various sources such as observations,
interviews, machine recorded events, and viewing sessions,

triangulation is possible. Gorden writes (1980),

One strong recommendation made more and more
often in studies of comparative method is that we
cease quibbling over which method is best, use
methods to fit the purposes of the study, and use
multiple methods whenever possible. This use of
multiple methods, each to cross-check or
supplement the others, is often referred to as
triangulation. (pp. 11-12)

By comparing information from various sources, some
phenomena that are brought up in the interviews also appear
in the fieldnotes. They are again visible in the videotapes
and commented upon in the viewing session. These phenomena
all circle around the purpose of the therapy, namely, to
achieve increased range of motion. The success of
"loosening up the shoulder" depends on the condition of the
shoulder at the beginning of each session: the pain or

discomfort the patient is able to endure in the course of

125
the treatment: and the intricate working together to

achieve a result.

Issues of Trustworthiness

In addition to using triangulation to show that
different data do describe the same event in different
ways, as just reported, it has also been used as a
technique to increase the probability that credible
findings would be produced (Lincoln & Cuba, 1985). Other
measurements taken were prolonged engagement at the setting
and persistent observations of treatment situations.

Apart from observing and recording treatment sessions
of one patient and one therapist for four and a half months
(see Table 3.1), another seven and a half months were
devoted to participant observations at the same setting.
During this time, one videotape was taken of the therapist
working with another patient, a man with the same
diagnosis, and observational notes were written of her
working with three other women, each of them suffering from
a severely sore shoulder. One of them had an idiopathic
frozen shoulder, the other two had injuries that resulted
in frozen shoulders. Many other sessions were observed and
documented in fieldnotes of the therapist working with
patients who suffered from tetraplegia, paraplegia,

hemiplegia, low back pain, neck and shoulder pain, and

126
arthritis. Some injuries were due to accidents, while
others were incurred while participating in sports. One
physiatrist, a woman, was videotaped when giving
manipulation treatment to three patients with back
problems, and later interviewed.

Although the preliminary analysis of these data are
not reported here, they have served as a backdrop against
which the primary data have been contrasted and cross-
checked. It was found, for example, that the physical
therapist applied the same treatment technique to patients
with frozen shoulders, but they were adapted to a level
that was tolerable for each patient, and her instructions
varied according to which phase each patient was in. The
patients themselves showed discomfort in various ways: some
would talk about it at great length, while others would,
more or less, grind their teeth. They also indicated when
pain had subsided in different ways. The man with a frozen
shoulder would slap his unafflicted arm on the treatment
table, as if to say, "I’ve had enough rest," while one of
the women would say, "Now I am ready to start again."

Equally important as using a variety of data have been
the presentations of the videotapes of Dr. Strauss and
Kathy Davis to different audiences. Paralleling the
analysis of the Videorecorded treatment sessions, various
segments of the videotapes that had been analyzed in detail

were shown to different audiences. Practicing physical

127
therapists, physical therapy students, teachers of physical
therapy, and other health professionals and researchers
have seen various portions of the videotapes.

During these presentations, the audience was first
given background information about who the patient and the
therapist were, their reason for being together, where and
when the treatments took place, and which part of the tape
was about to be shown. A brief segment of two to three
minutes was played a couple of times, then the audience was
encouraged to tell one another or the whole group their
impression of what they had seen, what they had noticed,
what they had heard. This always led to the revelation that
most of them had heard and seen different things. Many
would be upset with what they saw: they would question the
treatment that was given: they wanted to know more about
the history of the patient’s shoulder: they would find the
conversation between the therapist and the patient odd.
Such questions are to be expected when only a segment of an
ongoing interaction is shown. The participants expressed
the same bewilderment one experiences when one turns on the
TV without first checking what is being broadcast and is
"thrown" into an ongoing program. It takes a while to
figure out what is going on. After these initial reactions
were expressed, the participants started arguing their case
or arguing over their interpretations. This, in turn, led

to more viewings, more listening. The same segment was

 

128
shown several times, and the participants were here
encouraged to have the tape stopped at whatever place they
wanted. Instead of questioning or criticizing what they saw
and heard, the participants were guided to look at neg, for
instance, the patient moved her arm, hen the therapist used
her hands, DO! the two sequentially coordinated their
movements and their talk, and hey the patient showed that
something was hurting.

The participants were thus indirectly asked to adopt
an analytic stance toward the face to face interaction they
were observing. They would therefore leave with an
impression which many times was quite different from their
original one. They would leave with new insights about
something that had been salient to them. They would leave
still wondering nny the patient behaved as she did, and why
the therapist acted as she did.

These presentations served multiple functions. They
became introductions to how one can study naturally
occurring treatment situations. They became introductions
to the field of communication and microanalysis. They were
particularly useful to me, in that the "findings" reported
by the participants served as a validity test for my
ongoing analysis. This also forced me to continually
scrutinize and refine my transcriptions.

An unintended, but highly valuable, consequence of

some of these presentations was that some teachers of

129
physical therapy encouraged their students to be more
focused in their observations of patient/therapist
encounters during their clinical practice. One teacher told
how surprised she was when her students reported that they
only saw therapists treat patients, they did not see any
examinations or evaluations.

Other informal reports came from practicing physical
therapists, who had started to become more aware of their
own actions. Many said that they had never thought of, or
did not know, what they actually were saying to their
patients. Others would say, "I do exactly like the
therapist in your study. When the patient is grimacing with
pain, I tell her how well she is doing." For a discussion
of what scene in the vidotape these therapists were
referring to, and its eventual therapeutic value, see page

145.

Summary

This chapter has reported on a study of one patient
and one therapist whose contacts were originally assumed to
last for one month but ended up lasting four-and-a-half
months. The data collection process took altogether one and
a half years. The chapter tells of how participants were
chosen, and how original research questions were expanded

as viewing sessions with the participants were carried out.

130
The documentation of treatment situations on videotapes
allowed each scene to be revisited many times and that, by
itself, generated new questions. These were tested
systematically and some of the findings were confirmed
using what Lincoln and Guba (1985) refer to as peer
debriefings.

The therapist’s opinion of this patient being a "hard"
patient, as expressed in the viewing sessions, has been
used as one point of departure. Tying the therapist’s
utterances to the particular behavior that was displayed on
the tape led to looking for instances of similar behavior.
I discovered that part of the therapist’s perception of
this patient wanting to be "in charge" could be due to a
series of misreadings of contextualization cues. This will
be discussed in chapter five. The difficulties or episodes
of confusion to be discussed refer to lack of interactional
synchrony, with the diagnosis, the unstable condition, the
physical therapy treatment playing a minor role but always

being present.

SECTION II

DESCRIPTION AND ANALYSIS OF THE FINDINGS

CHAPTER FOUR

DOINGS AND TALK DURING MANUAL TREATMENT

Chapter four is divided into two parts. The first one
is centered around the physical actions the patient and the
therapist perform, the second one around the talk that the
two engage in during treatment. Part I first gives an
overview of the manual treatment on May 3, 1984, then shows
how it is organized into different phases. Part II follows
with a description and analysis of the treatment technique
itself, and the identification of the critical moment for
improvement during the stretch. A characterization is then
given of the two different phases. The implicit goal of the
treatment is stated along with arguments that this, to a

large degree, determines how the session turns out.

Part I

The Doings of the Patient and the Therapist

The treatment session on May 3, 1984 is the major data
source on which the analysis reported here rests.
Throughout the session the patient lies on a treatment

table and the therapist sits on a low chair with wheels.

131

132
The session starts with the therapist giving ultrasound
over the patient’s right shoulder joint and shoulder
muscles. It is followed by the manual treatment which lasts
for approximately 20 minutes. The treatment ends with the
patient sitting up on the table and the therapist standing.
Both are pleased with the result achieved today. They joke
and laugh. Before the patient leaves, agreements are made
about the following session.

Before giving details about today’s session, an
important difference between the patient and the therapist
regarding the condition itself needs to be stated. The
initial knowledge a therapist has about a patient is
through the prescription, which states, in a sense, that
this person suffers from something, or "has" something. The
patient’s condition is now a "fact" for the therapist. The
patient in this study has had the problem for almost a
year, so it has been a "fact" for her much longer. She
knows a lot about her sore shoulder. This does not mean,
however, that she understands why she got a frozen shoulder
in the first place, or that she has "accepted" it, or that
she has accepted that an ordinary movement with her arm can
cause such pain.

The therapist, on the other hand, has no difficulties
in accepting the patient’s condition. Her first evaluation
confirms the diagnosis and lists "Presence of pain,

decreased ROM, and decreased strength" as problems. The

133
goals to be obtained are "Relief of pain, increased ROM and
strength" (Patient evaluation form, 1/9/84). In the
prescription the therapist received, there is no indication
of how range of motion is to be increased. That is left for
her to decide. The therapeutic technique she uses is called
stretching.

Returning to the session on May 3, 1984, late in the
series of treatments, the patient is here close to
achieving full range of forward flexion, that is, she is
almost able to bring her arm all the way over her head. She
has greater problems in rotating her arm outward, a motion
necessary, for instance, in combing one’s hair. These two
directions, forward flexion and external rotation, are
being worked on in this session. Not only do they

alternate, they are also separated by minutes of rest.

ses of ch' " ands- "
s s f e ove " ds- "

During the manual treatment two phases were found to
alternate continously. One consisted of the specific
treatment, the stretching, where the therapist kept one or
both hands on the patient’s arm. This phase is called
"hands-on." The moment the therapist has placed one hand on
the patient’s arm is considered the beginning of a hands-
on phase. It continues until the therapist has removed her
hand from the patient’s arm. In the other phase, the

therapist does not touch the patient and that phase has,

134
accordingly, been called "hands-off." There are few
exceptions to this rule, but the purposes of touch during
phases of "hands-off" were not intended for stretching.

When looking at what the patient’s arm "does" during
the treatment, during the "hands-on" phases the arm is held
still in almost the same position. In contrast, during the
"hands-off" phases the patient moves her arm in all
directions. If the patient’s arm had been used as a
criterion for labelling the different phases, instead of
the therapist’s hands, the phase would have been labeled
with something like "Stationary position of the patient’s
arm" versus "Free movements of the patient’s arm."

An overview of the phases during the manual treatment
is provided in Figure 4.1. The horizontal line is the time
line. It shows the length of the treatment and of each
phase.

The manual treatment lasts for 19 min. 25 sec. and
consists of 15 phases. There are 8 hands-off phases and 7
hands on-phases. The last hands—off phase is over when the
patient sits up on the treatment table. Later on in the
text the phases are referred to as hands-off I-VIII and
hands-on I-VII. The patient and the therapist work in
forward flexion in hands-on I, II, VI, and VII, and in

external rotation in hands-on III, IV, and V.

135

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Along the vertical line, the number of stretchings
carried out per hands-on phase is noted. Two stretchings
per hands-on phase are carried out in hands-on I, VI, and
VII, and three in the remaining hands-on phases. All
together 18 stretchings are performed during the seven
hands-on phases. Only two of them are judged successful and
acknowledged as such by both the patient and the therapist.
This happens at the end of hands-on V (external rotation)
and hands-on VII (forward flexion), and is indicated in the
figure with an S. Direction is changed twice, after hands-
on II and hands-on V.

To distinguish the hands—on phases from the hands-off
phases, the former are represented as filled bars. The
direction that has been worked on is indicated in
abbreviated forms within each filled bar. FF is forward
flexion and ER is external rotation.

Thus one can see that the session starts and ends with
two phases of forward flexion, surrounding three phases of
external rotation. All of the phases vary in time. The
first 7 or 8 minutes of the treatment are quite different
from the last 11 to 12 minutes. There are more hands-on
phases, short periods of recovery, and the impression is
that intense work is going on here. In the latter part of
the treatment there are only three hands-on phases, with
one quite long period of recovery, but it is here that the

treatment is successful.

137
Why the session came to turn out this way is

discussed through the rest of the thesis.

W

The manual treatment used here is a form of
stretching. The primary reason for limited mobility is the
contracted capsule that surrounds the shoulder joint.
Secondarily, a shortening of muscles has occurred. By
stretching the muscles, indirectly an elongation of the
capsular fibers will be accomplished.

In order to carry out the stretching, the therapist
must place one or both of her hands upon the patient’s arm.
The patient lies on her back on a treatment table and the
therapist sits on a chair next to the patient’s right side.
There are wheels on the chair, so the therapist can easily
move along the treatment table..

Based on the analysis of video X (5/3/84), the
technique to increase forward flexion is as follows. The
patient herself brings her right arm to a starting
position, which means as far up as possible to a position
where it does not hurt to hold the arm. The therapist then
places one hand on the patient’s upper arm, whereupon the
patient is asked to contract certain groups of muscles,
working against the pressure of the therapist’s hand. No
movement should take place in the joint, that is, an

isometric contraction is required. When the contraction has

138
been held for a certain amount of time, a matter of
seconds, the patient is asked to relax the same muscles,
and keep them relaxed as the therapist brings the arm
further up. It is important that the patient not resist the
therapist’s moving of her arm. Sometimes the patient is
asked to actively move her arm at the same time as the
therapist. Even so, it is always the therapist who brings
the arm as far up as possible. Passive range of motion
always exceeds active range of motion.

The therapist keeps the arm in this extreme position
for some time. The patient is unable to reach this position
by herself. If possible, this position becomes the new
point of departure, the starting position for another
stretch. If it is too painful, the therapist lowers the arm
slightly. This four-step procedure is repeated two to three
times before the therapist brings the arm down and the
patient is given time to rest and recover. The moment the
arm is lowered, the pain starts to subside.

In analyzing the stretching from the outside it looks
as if all that is required of the patient is to bring her
arm to a starting position, contract certain muscles, and a
few minutes later relax them and keep them relaxed. When
the therapist brings the arm further up, the patient is
supposed to let this happen passively, to "do nothing," or,
if so instructed, to move the arm at the same time as the

therapist. It also looks as if the therapist only tells the

139
patient to first contract some muscles, then relax them. A
few seconds later she moves the arm a little bit.

This seemingly simple technique demands a high degree
of concentration and sensitivity on the part of the
therapist, both with respect to the verbal commands she
selects and to the use of her hands. The verbal commands
the therapist uses are mostly "Push" or "Keep pushing" and
"Relax" or "Let go." "Push" and "Keep pushing" refer both
to the gradual build up of muscular tension and to the
stationary phase of the contraction. "Relax" refers to the
gradual release of tension and also to the state of
relaxation. Many times an "Okay" replaces any of these
commands. How that is to be interpreted depends on when it
is uttered and what the therapist instructs with her hands.
The therapist has to steer the patient’s physical work by
means of her hands through gradually increasing resistance:
encouraging isometric contraction without breaking or
defeating it: and lightening the pressure and waiting for
the relaxation to occur while supporting the arm. When she
has felt the patient "let go," she moves the arm to the
point where limitation is again felt to occur.

The therapist thus holds her hands in the same place
through the whole sequence. The difference lies in the
amount and kind of pressure she uses. When the patient
contracts her muscles, the therapist exerts so much

pressure (resistance) that the patient cannot perform any

140
motion in the shoulder joint. During the relaxation the
pressure is reduced, and during the stretching itself
pressure is increased. The therapist moves the arm in the
opposite direction from the direction the patient has been
working in.

In spite of having done the same stretch in seven
sessions, the patient is still confused about what
constitutes one complete stretch. In one session (Video V,
2/1/84) the therapist says, after the patient has brought
her arm to maximal forward flexion, "We’re gonna do oh do
our usual routine." She continues, "Move back. Three times.
Now the three times mean you. You pushing. You relaxing.
And me pushing." The patient says she understands but adds
" .. my end of the third is your? What I thought was the
end of the third is the beginning of the fourth." Now, "the
end of the third" is the moment the therapist is keeping
the patient’s arm at the newly achieved maximal position.
This is exactly where the next sequence starts, that is,
where the patient is supposed to contract her muscles
again.

A few seconds later, as they go on working, the
patient asks "Is that one whole one or is it one and a
half?" The therapist replies "Well this is the start of the
second one. Whenever you push you’re starting another one."

From this it can be inferred that the patient has

difficulties in discriminating between the pressure the

141
therapist applies when she moves the patient’s arm and the
pressure the therapist uses when providing resistance.

What do the patient’s comments stand for? Do they mean
that the patient incorrectly perceives the therapist’s
pressure, when keeping the arm at the new position, as an
indication to start contracting her muscles? Or is it that
the patient has difficulties "knowing" whether she has
contracted her muscles voluntarily or involuntarily so as
to "safeguard" them? Muscle spasm is known to serve as a
protective phenomenon to prevent movement that is painful
(Cailliet, 1981).

The therapist’s comment, "Whenever you push you’re
starting another one," gives, in a sense, the
responsibility for initiating each new sequence to the
patient, while the patient seems to be considering the
commands from the therapist’s hands to be the "starter."

The therapist’s explanations are another way of saying

to the patient:

You do not have to think here. All you need to do
is to follow my instructions. That means just
contract your muscles to push against my hand,
then stop doing that and let the muscles relax.
Then I will do the rest.

But the patient says:

I am following closely what you are doing. I keep
track of what is happening by counting the number

142
of stretches we do or you make me do. I am

thinking at the same time as I respond to your
instructions.

This example has been selected to demonstrate three
features. First, the physical closeness and the attention
that is required by the therapist and the patient to carry
out the stretching. Second, the patient’s eagerness to do
what is asked of her correctly. Most of the direct
questions the patient asks the therapist, across sessions,
concern just that. Third, it shows that the patient pays
close attention to what is going on, but that she
experiences the stretching in a way that is different from
what the therapist intends. What the therapist considers
one complete stretch is counted as two by the patient.

We now turn to the moment in the treatment that is

critical for improvement.

' ’ t ' tc
The time when the therapist holds the patient’s arm at

the maximal position is the time and the situation where
improvement can occur. It is the time when the capsular as
well as the muscular fibres are elongated. This extreme
position of the arm can be very painful because of the
activation of nerve endings, sensitive to tension, in the
capsule. What Cailliet (1981, p. 85) calls stretch pain

occurs when forceful movement is attempted.

143

The success of this critical moment depends on how
much discomfort the patient can endure and how sensitive
the therapist is in judging the patient’s level of
tolerance. If the therapist holds the patient’s arm for too
long in the extreme position, it will take longer for the
pain to subside and treatment time will be reduced.

In viewing sessions, the therapist and the patient
separately comment upon the same moments in the treatment,
indicating that there are certain instances they are keenly
aware of. One of these is the time when the patient is
supposed to be relaxed and let the therapist move her arm
as far up as possible.

The therapist says the following:

It is my arm when we stretch it and then she can
have it back to relax. And she knows that. But
basically, she is fearful of the pain and I don’t
know whether she trusts me enough or not, but it
is the fear of the pain that she would like to
keep the arm to herself and not let anybody mess
with it. That really causes a problem in her own
recovery, because when that fear is there and the
tension, then the muscles are not as relaxed and
you don’t give as much for the stretching purpose
and in general, get better slower. (Viewing
session, video V, 3/8/84)

The patient talks about the same phenomenon in this

way:

Well the thing is, because you kncn, that as soon
as you let go that she is gonna pull it up and
it’s gonna get to a certain point and it’s gonna

144
hurt.... And it’s hard to relax when you know if
you relax, that’s a signal for them to hurt you
agree ((laughs)).... As long as I pushed I was
safe. As long as you push against her arm you’re
safe. And you know the minute you let go, then
she is going to hurt you some more.... And to
know that, ccing what you’re told to do, is then
going to bring on something horrible. Which is
moving it further. (Viewing session, video I,
8/1/85)

In the therapist’s description, the two phases are
separated according to who has the right to do what with
the patient’s arm. As a therapist, she claims ownership
over the patient’s arm as long as she has her hands on it.
But she cannot carry out the treatment properly unless the
patient relaxes her muscles. In a sense the patient is
attributed the power to prevent progress by not relaxing.

The patient, on the other hand, is well aware of her
reluctance to and difficulty in letting her muscles go. She
knows that when this happens, she no longer has control
over her arm--the therapist does. Besides, there is no way
the patient can hide her reactions from the therapist. This
is clear in another session. When the patient performs
internal rotation, assisted by the therapist, the therapist
says with rising intonation "Can you just relax?" The
patient exhales and says "I always think I am relaxed. [..]
Just because I’m two inches off the table that makes you
think I am not relaxed? Hm?" (Video I, 1/18/84). Both
laugh. Thus the therapist sees what happens: she hears the

patient exhale, and her hands know what is happening with

145
the patient’s arm. The patient’s doings during both the
hands-on and hands-off phases are closely monitored by the
therapist. But during the hands-on phases, the patient is

literally in the hands of the therapist.

t o s- se

Characteristic for a hands-on phase is that this is
where real work takes place. This is where the patient’s
'arm is kept in the same position most of the time. This is
where the stretching is carried out. It does not mean,
however, that work starts and stops with the therapist’s
placement and removal of her hands, because the therapist
can put both her hands on the patient’s arm and keep
talking about some TV program. She can also, after a
stretch, start to bring the patient’s arm down, stop
halfway, and rub the patient’s shoulder before she lets go
of the arm. The patient can decide when to place her arm in
the proper starting position, but she cannot decide when to
bring the arm down. That is up to the therapist. The moment
the therapist has removed her hands, the scene changes. A

hands-off phase has started.

WWW
At the beginning of each hands—off phase the patient
moves her arm slowly. It is a way to get rid of the

stiffness the stretching itself inadvertently led to.

146
Rarely is she instructed to do this. The patient moves her
arm in all directions, bends and stretches the elbow,
reaches toward the ceiling. She stays away from getting
close to the position the arm was held in during the
preceding hands-on phase. Temporarily she brings the arm
down on the table to rest. During the hands-off phase there
is recuperation, rest, assessment of what has happened
during the previous phase, and preparation for the next
one. This preparation can be described as follows: The
patient has "warmed up" by moving her arm around before
placing it in the starting position: her arm is held still
in that position: the therapist sits close to the patient
and has stretched or is stretching her back: eye contact
has been established and disengaged: the patient now faces
the ceiling: a conversation is finished or is about to be

finished. The next hands-on phase is about to begin.

ow ss' 3 to ' e

WW3;

The session thus becomes organized into phases of
hands-on and hands-off. The ultimate goal of the treatment
itself is to accomplish a physical change in the patient.
It is clear that "something is going to happen" in the
session. The whole treatment is geared toward "loosening"
up the patient’s shoulder. Both the therapist and the
patient concentrate on this. The therapist continuously,

and in various ways, encourages the patient to endure the

147
discomfort of the treatment and the patient says, "If it
hurts it must be good for me" (Video V, 2/1/84).

The treatment as a whole can be described as a series
of attempts to ”loosen up" the shoulder, attempts that can
be successful or not. There is a gradual buildup to achieve
a positive result in that at least two stretchings are
carried out within each hands-on phase. The outcome of each
single stretching in a sense drives the treatment forward.
Based on the patient’s reactions and on what has happened
in the shoulder, it can have loosened up a little or it can
have remained stuck, the therapist decides what to do next.
She can either do another stretch, or she can bring the arm
down, let the patient rest and then make another attempt. A
third alternative is to work in another direction after a
few minutes of rest.

The outcome of each complete hands-on phase can also
be characterized as a success or a failure depending on
what has actually happened in the shoulder. Both the
patient and the therapist acknowledge verbally that the
shoulder indeed has "loosened up" on two occasions (Video
X, 5/3/84). Characteristic for most sessions is that there
are many attempts, but few of them are successful.

Looking again at Figure 4.1, one sees that the working
direction has been changed twice in the same session. The
analysis of when changes have taken place and when working

directions have been maintained shows that the therapist

148
has followed these principles. A change in working
direction can take place either because there have been too
many failures or because a positive result has been
obtained. The decision to continue working in the same
direction is based on the same premises. Either there has
been a series of failures, and the therapist does not want
to stop before something is achieved, or something has been
achieved, but there is still a chance that more can be
gained.

The patient never explicitly suggests either a change
or a maintenance of working direction. But her contribution
to continuing working in the same direction should not be
underestimated, as she many times places her arm in a
starting position without being instructed.

The therapist’s seemingly arbitrary changes were not
explicitly expressed as a problem by the patient, but in a

viewing session she reports,

I don’t recall.... that I had the feeling....
that there was a pattern that ’Now we’ve gotten
twc of ’em out of the way, there’s only one to
go.’ I don’t recall that I had the feeling of
seeing this pattern, that first we do chic, then
we do £hi§: then we’re gonna do IDA; and then
it’s over.

There was one I disliked a lot. I think it’s the
over-the-head thing that I hated the worst. And
then sometimes, after it had gotten kind of
lccsened up, she would say she wants me to do
mere of ’em. And I would feel that I had already
dcne them and shouldn’t have to do ’em again. But
she would say ’But we’ve got it so nice and
loosened up’ and I’d usually go ahead and do
more. (Viewing session, 8/1/85)

149

In this excerpt we see that the patient perceives the
therapist to solely decide how many stretchings to carry
out. There is no way she can keep track of what is going to
happen. But, again, she is ready to do what is asked of
her.

To summarize, the therapist’s hands are used as
instruments in the treatment. Along with commands and
encouragements the patient’s arm is brought to a position
she could not have accomplished herself. Since this
position is uncomfortable, the arm cannot be held there for
too long. The moment the arm is brought down, pain starts
to subside. Thus a pattern is established where phases of
stretching alternate with phases of rest. All phases vary
in time.

A rough analysis of "who is in charge" during the
alternating phases can be summarized in the following way.
It looks to the researcher as if the therapist has the
power to solely decide when to bring the arm down and,
consequently, the number of stretchings in each phase. It
is true that it is not the patient herself who lowers her
arm, but her influence upon the therapist’s decision should
not be underestimated. The patient’s reactions and
responses to the treatment are fully displayed during the
session, in words, sounds, and facial expressions. This in

turn leads to verbal negotiations preceding each lowering

150
of the arm, particularly during the last four hands-on
phases.

When looking at Figure 4.1 one can, for instance,
assume that hands-on V, which consists of no more
stretchings than in the other phases, occupies so much time
because the therapist prolongs the critical moments. And
the extremly long hands-off phase VII might be due to the
patient needing an extra long time to recover from the
previous hands-on phase. However, it is not solely the
length of the specific treatment and the time for recovery
that is displayed in the figure. Rather, talk can cause

phases to be extended.

Part II

Talk During Manual Treatment

The analysis of what is said and talked about during
the manual treatment on May 3, 1984 starts with reporting
how much time is occupied by talk and by silence, and how
much the therapist versus the patient talks. This
estimation is arrived at by tallying first each turn of
talk, then each sub-unit or functional unit of each turn,
as described in chapter three. The assumption that the
therapist has the floor during the hands-on phases is

discussed. Then the form and the function of the patient’s

151
and the therapist’s speech are analyzed and characteristics
of their speech provided.

The content of the talk has been studied and is
reported in three sections. The first one relates to what
the patient reports about her shoulder, the second the
theme the patient brings up most frequently and how the
therapist responds to this, and the last one concerns how
the two comment upon what is happening during the ongoing
treatment. Part II concludes with the assertion that the
therapist considers that they are doing very well, while
the patient is not pleased at all. Strikingly different

interpretations are thus revealed.

Time of Talk enc Siience

All the nence;cfifi_nne§ec last together 10 min. 16 sec.
Out of this 8 min. 3 sec. is spent talking and 2 min. 13
sec. is spent in silence. Silence means here absence of
sounds, not absence of movements. Appendix G gives an
example of what happens during 10 sec. silence in hands-
off VI. The mean for a hands-off phase is 1 min. 17 sec.,
the median 1 min. 4 sec. The hands-off phases range from 3
min. 44 sec. to 29 sec. The hence;cn_nnnee§ last together 9
min. 9 sec. with talk taking place during 4 min. 54 sec.
The remaining 4 min. 15 sec. is spent in silence. The mean

for a hands-on phase is 1 min. 18 sec., the median 1 min.

152
16 sec. The hands-on phases range from 2 min. 36 sec. to 38
sec.
Talk takes place throughout the phases, while physical
contact is restricted mostly to the hands-on phases. The
talk is first categorized and tallied as turns (see Table

4.1), then as functional units (see Table 4.2).

Table 4.1 Distribution of the Number of Turns Occurring in
all Hands-Off and Hands On-Phases

 

MI W Total
Therapist 64 61 125
Patient 68 55 123

 

This table shows that there is virtually no difference
between the number of turns uttered by the patient and by
the therapist when they are added up. The patient has a few
more turns in the hands-off phases, the therapist a few
more in the hands-on phases. When looking at the length of
each turn or how much is uttered within each turn, there is

however a difference (see Table 4.2).

Table 4.2 Distribution of the Number of Functional Units
Occurring in all Hands-Off and Hands-On Phases

 

Bandszgff mg!) Total

Therapist 108 144 252
Patient 101 69 170

 

153

The only quantitative difference between the patient’s
and the therapist’s talk is to be found in the amount of
functional units during the hands—on phases. The
qualitative analysis of the utterances shows that the
functional units can consist of complete sentences:
incomplete sentences: single words: sighs ("Ah"):
backchanneling signals such as "Uhum," "Hm" and audible
exhalations. The therapist expresses more than twice as
many functional units as the patient, all done through
words and backchanneling signals. Even during the hands-
off phases this is how the therapist speaks. The patient,
on the other hand, uses expressions such as "Ah," "Oh" and
audible exhalations in 25 cases of 69 (36%) during the
hands-on phases, but during the hands off-phases this
happens only 6 times out of 101. Thus there is a difference
in the way the therapist and the patient speak during
hands-on phases. The patient not only speaks less, that is,
uses fewer functional units, she also uses a different
language, such as vocalizations.

These differences in talk during hands-on phases
support the assumption about the therapist’s dominance
during the hands-on phases, when judged from the
transcription of the vocal communication. It certainly
looks as if the therapist is in charge. When extending the
analysis to include the non-vocal behavior, we find that

there is a regular giving and taking of turns here as well.

154
The difference in the number of functional units is due to
the fact that the therapist’s encible instructions are
tallied, while the patient’s eilenc, physical responses are
not. Thus there is a dialogue between the patient and the
therapist even during the hands-on phases. In fact, a
particular creccmen§_gielcgne begins to emerge from this
analysis. It can be described as the therapist instructing
the patient, verbally and physically, to do something. The
patient responds immediately with her muscles, but also
with comments about how she feels. This happens
particularly when the therapist moves the patient’s arm.
One third of these "comments" are vocalizations (Trager,
1964) indicating that the patient is in pain.

Temporarily setting aside the importance of including
non-vocal behavior and paralanguage when analyzing talk,
the study now turns to categorizing solely the vocal
communication. First, a description of how the talk has
been categorized according to style is presented, then the

main features of the therapist’s and the patient’s talk.

0 o s
The stretching is central to the session. The session
itself can be described, in a reduced form, as "the
therapist tells the patient what to do: the patient does as
instructed: the therapist evaluates the patient’s

performance." It is important to note that the patient is

155
not required to respond in words to the therapist’s
instructions, except during the physical examinations the
therapist performs. Still, the patient does talk. What is
it, then, that she has to say? What is characteristic of
her talk and of the therapist’s talk? What is the function
of their talk? It is important to take a close look at the
talk itself, since it informs us about the relationship
between the patient and the therapist.

When looking first at the way the two talk, both use a
style defined here as "making conversation." This term
"making conversation" has been selected as representative
of the most ordinary way people talk. One feature of
ordinary talk is its spontaneity: another can be the
framing used, for instance, when retelling an event or
relating a narrative: a third the lack of imperatives.
Implicit in the use of this term is, however, its
association with the fact that any utterance can be the
beginning of a conversation. An ordinary statement can
become a short exchange of a couple of phrases, or it can
turn into a lengthy discussion. Whatever the outcome, it
depends upon the "uptake" of the interactional party.

Another implicit feature of the term "making
conversation" is that conversation is a noun that stands
for an activity, an activity consisting of people talking
about something. Thus a topic is always involved. Any

sentence contains or has a topic. Every conversation has

156
one or more topics, but this is always worked out in the
process of talking. In line with this, instead of saying,
"The therapist or the patient starts to talk about
," the term "takes initiative to conversation" has
been used, even if it turns out that the conversation
itself is very brief.

The patient’s style of talk is represented only in one
category, "making conversation," while the therapist’s
style of talk appears in three. This discrepancy is largely
due to the therapist’s occupational role, and the
categorizations of the styles of her talk are based,
partially, on the concrete tasks she performs (see Table
4.3). In other words, the function of her talk is connected

to the particular activities that take place.

Table 4.3 Categories of Styles of Therapist Talk and
Patient Talk

 

W ’e Ta
A. Giving instructions and feedback A. Making
related to the treatment conversation

B. Asking questions and giving
feedback while doing examinations

C. Making conversation

 

Tables 4.3 and 4.2 both show differences in the patient’s
and the therapist’s talk, with the therapist having longer

turns or more functional units than the patient and

157

shifting styles of talk. Figure 4.2 indicates that the
therapist’s styles of talking vary according to the
activity at hand, but that the patient’s style remains the
same across activities. As Figure 4.2 includes the category
"taking initiative to conversation," the patient’s role
becomes more salient. Omitted in the figure are, however,
the responses by the patient and by the therapist to each
other’s utterances, but they are discussed in the text.
Since references will be made to Figure 4.2 throughout the
remainder of the thesis, additional remarks are in order.

Each phase in Figure 4.2 is marked exactly as in
Figure 4.1 with respect to length of time. In each hands-
on phase, where the stretching occurs, there are
instructions and feedback. In addition, they appear in four
hands-off phases. Three examinations are carried out during
this session, one of them at the very end. The therapist
takes initiative to conversation only in three phases, all
of them during the second half of the treatment. Note that
her initiatives co-occur with the episodes of confusion.
This will be discussed in detail in chapter five but also

in the following section.

158

 

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159
W

The styles of the therapist’s talk are labeled as
W? W
We: and making
29.0mm.

The fnnccicn of the talk that is related to the
treatment, that is, the category "giving instructions and

feedback," can be divided into three subcategories.

l. Commands in preparation for the stretch with the
specific purpose of finding a "painfree starting
position"

2. Commands related directly to the stretch and
addressed to the patient’s shoulder, like "Push" and
"Relax"

3. Evaluative comments on the patient’s performance

All three are illustrated in the following example, "Yeah.
That’s good. It really looks better than when we started
out. Let me get it out to the side. Is that painful? At
that place? You do better at this one? [....] Okay. Go
push" (Video X, 5/3/84). The evaluative comments are:
"That’s good. It really looks better than when we started
out." The commands to prepare for the stretch are: "Let me
get it out to the side. Is that painful? At that place? You
do better at this one?" The commands related to the stretch

itself are: "Okay. Go push."

160

The category "9iXiD9_iDSLIBQEiQn§_§n§_£§§QDQQK"
occupies almost 2/3 (62%) of the therapist’s functional
units during all phases. Most of them are commands and
evaluative comments regarding the stretching itself. They
are to be found in every hands-on phase. Instructions also
are given in four of the eight hands-off phases (see Figure
4.2). Three are preparations for the following hands-on
phase. The first one (hands-off I) indicates the transition
from the ultrasound treatment to the stretching. The second
one (hands-off III) and the third one (hands-off VI) are
related to changes in working direction. In hands-off VII
the instructions are of a different kind. One is an
instruction to the patient to rest: two are related to
finding a painfree starting position.

The commands and the evaluative comments that are
expressed in the hands-on phases are coordinated with the
messages the therapist gives with her hands. Her reliance
upon the hands is to be inferred from the utterances "It’s
good. [...] Okay. Let’s start there. [.....] Okay and
relax. And roll back" (Video X, 5/3/84). Instructions could
also have been coded as "responses" to something the
patient does. One can say that the therapist does talk back
to the patient’s physical actions, as in "Roll back. Let it
go. Reaching back. Let it go. It’s still going. You’re
doing reel well." The phrases "Reaching back" and "Let it

go" are instructions as well as responses to the patient’s

161
muscular contractions and relaxations. The phrase "It’s
still going" is uttered immediately after the patient has
turned her head and looked at her arm. When the patient a
second later grimaces with pain the therapist says "You’re
doing reel well."

This last phrase by the therapist is worth a special
commentary. It is uttered, with emphasis and in an
appreciative tone of voice, exactly at the same time as the
patient looks as if she is experiencing the worst kind of
pain. She has her eyes closed, her whole face wrinkled. The
patient is not doing well at all. She is in pain. The
contrast between what the therapist says and how the
patient feels is striking. One interpretation is that the
therapist is not empathetic with how the patient feels: she
ignores it. Another is that she is trying to encourage the
patient to endure the pain a little bit longer, because she
feels something is happening with the patient’s shoulder. A
third is that she in fact is instructing the patient to
"hang in there" but using positive words.

As each utterance can have multiple/simultaneous
functions, it is difficult to distinguish whether an
utterance is only an instruction or only a feedback or only
a comment upon how things are going. The category is
therefore composed of both instructions and feedback. The
expression "It’s good" can be a positive feedback, but it

can also be an instruction to stop. It is worth noticing,

162
however, that some, as in the previous example, can be
distinguished as "praise." Some are uttered directly nicer
a stretch is completed, but most of them are uttered at the
end of a stretching sequence, when the patient reveals her
discomfort. The function of these can be to ask/instruct
the patient to endure the pain a little bit longer. Talking
takes time and a strategy the therapist might use is to
merely utter a phrase to prolong the critical moment.

The commands regarding he sta t n 0 on occur
three times and occupy only eight functional units.
However, they are included for three reasons. Their
functions are ambiguous. They are expressed at the end of
the session. It is something the patient should know and
does know about after four months of treatment. The first
one is expressed in hands-on VI, the two others in hands-
off VII (see Figure 4.2). Besides, they are all involved in
the "episodes of confusion" to be discussed in detail in
chapter five.

Characteristic of the second category, eeking
eL-= ... a 1 - I. -eqsa . w; .e ..1,. t..I I: 'cns, is
that the therapist asks her questions at the same time as
she examines a particular area of the patient’s shoulder
with her hands. The purpose of the therapist’s talk and
doings here is to find out something about the patient’s
shoulder. This is different from the talk that is related

to the stretching, which is to make the patient do

163
something. For example, the expression "Not hurting that
bad Yeah Not hurting that bad right there," indicates that
the therapist wants, and gets, some information from the
patient. She gets this both through asking and through
touching. She gets the answer she seeks quite fast.
Imbedded in the way the therapist phrases her questions and
in her fast feedback is that the therapist is almost sure
that "It is ncr hurting that bad right there," that the
pain in that particular area is not a serious problem for
the patient, or that the therapist needs to do something
about it.

It is as if the therapist, at the same time as she
elicits information from the patient, has a conversation
with the situation itself and says, "I’m just checking. I
want to confirm that my perception of your status is
correct."

Three brief examinations are carried out, two during
hands-off phases and one at the end of a hands-on phase
(see Figure 4.2). The first one concerns a sound that is
heard from the shoulder joint as the patient moves her arm
(hands-off II): the second one pain in the back of the
patient’s shoulder (hands-on V): the third one a comparison
of mobility in forward flexion between the patient’s arms
(hands-off VIII). Although brief, these examinations serve
other important functions. This will be discussed in

chapter five.

164

The third category, meking_ccnyer§ecicn, refers to
another style of the therapist’s talk. The topic of the
talk here is not directly related to the stretching itself
or to the examinations, but includes bringing up issues
outside of the ongoing treatment as well as talking about
future plans. Part of this category is also the way the
therapist talks as she is being drawn into conversations by
the patient. Of importance are the three occasions when the
therapist inirieree_ccnyereericne, as they deviate from her
most ordinary way of talking. The first topic, in hands-on
V, concerns a TV program: "Well the tune that goes through
my head is ‘This is it.’ You know that half an hour
program." The second one, in hands-off VI, is a change in
the present treatment plan: "You do good with rest in
between." The third one, in hands-off VII, is a suggestion
to stop the ongoing treatment at a certain point in time:
"It doesn’t matter to me whether we do it another time or
not." The responses to what the patient says, which also
are part of the style of meking_ccnyereecicn, occur every
time the patient brings something up. That happens in all
but two of the fifteen phases. How the therapist responds
to some of the patient’s comments is discussed under the
heading "The Theme Brought Up Most Frequently by the

Patient" and is reported in Table 4.4.

165
e 's ’

The function of the largest part of the therapist’s
talk has proved to be giving instructions and feedback.
That happens in eleven out of the fifteen phases. The
commands related to the stretchings are, with only a few

exceptions, brief impernrigec. The examples are many, e.g.,

Go push. Give it a real hard push.
Rela::x. Reach.

Keep breathing.

The commands related to finding a painfree starting
position are mostly inrerrcgeciyee, such as "Which spot do
you want?", with a rising intonation at the end of each
functional unit, "Is that painful? At that place? You do
better at this one?". One command is formulated very
indirectly, like "Sometimes it’s finding the right spot."
Another is an imperative, "Yen pick out the spot that you
think is gonna do best." The feedbacks and the evaluative
cements are Wires-

As reported earlier, many of the "questions" the
therapist asks are just another way of giving instructions.
However, a summary of the therapist’s talk that has the
form of a question will be given. Questions dominate during

the examinations.

166
Is it my hand or your shoulder? (hands-off II)
Not hurting that bad? (hands-on V)

How far does that one go? (hands-off VIII)

Questions are also used before the stretching starts
(hands-on VI and hands-off VII), that is, in the search for
a "painfree position," and towards the end of the hands-on
phases when the patient displays some discomfort, for
example, "Wanna have it back?" (hands-on I).

Two other questions which fall outside of these
instances are significant. Both are uttered by the
therapist immediately after the patient has made a slight
grimace of pain which is not related to any critical moment
of a stretching. It happens long after a hands—on phase is
over. The first one, "Ie in gender chere?", is uttered at
the beginning of hands-on IV as the patient is touching the
upper part of her right shoulder and at the same time is
making a painful grimace. The therapist has placed her
right hand on the patient’s arm but the stretching has not
yet started. The patient answers with a slight nod. Later
on in the treatment both return to this question.

The second one. "WW
direcrian", is uttered when the patient, during hands-off
VII, moves her arm horizontally, while showing some
discomfort. The patient shakes her head and says "I do that

with my weight."

 

167

With these examples it is useful to point out some
important aspects of the therapist’s questions. Eirer, her
questions are brief, simple, and direct. They require only
a simple answer. All but two of the questions the therapist
asks throughout the session are to be answered with a "yes"
or a "no." This feature is characteristic of all the
questions the therapist asks. fieccng, the questions seem to
be uttered incidentally, revealing most of all that the
therapist has "heard" that the patient has communicated
something strictly behaviorally. Or the questions can be
interpreted as if the therapist is merely asking the
patient for confirmation that she has perceived properly
what the patient already has said--without a word. This is
also typical for the questions the therapist asks during
the stretching itself. In other words, there are few "true"
questions. There is little information the therapist does
not already have access to.

While her questions may not seek new information from
the patient, they are signs of the therapist’s attention to
the patient’s discomfort even when it is not caused by any
stretching. The rule is that pain during the stretching
itself is natural or to be expected. If the patient hurts
on other occasions, it must be probed into. rnirg, even if
the patient is required to respond with a simple yes or no,
she goes on to provide more information or she qualifies

her answers. All the questions the therapist asks, apart

168
from those that are part of the stretching itself, are
taken seriously by the patient. She interprets them as true
questions, that is, she assumes that the therapist wants
certain information from her, and tries to answer them as
correctly as possible, even if time is not allotted at the
moment the question is asked. This is characteristic for
this patient’s way of attending to questions throughout the
sessions.

Typically, the form of the therapist’s talk during a
hands-on phase shifts from, for example, telling the
patient what to do, to giving positive feedbacks, to asking
the patient to endure the critical moment a little longer
(see Appendices F and G). Besides, the therapist is
interrupted by the patient’s comments and has to respond to
them. When looking at the session as a whole there is a
difference between the first and the last hands-on phase.
During the first three hands-on phases the therapist
responds fast to the patient’s expression of discomfort and
brings the arm down, without discussion. During the
following hands-on phases, she tries to extend the critical
moment in that she gives lots of praise, which is uttered
exactly when the patient grimaces with pain and can’t speak
normally but has to whisper. She also asks the patient,
directly or indirectly, to go on. For example, "We can stop
and then we can go a little further. You wanna do that?",

and "Can you do one more time?". What is noteworthy is the

169
shift in the therapist’s talk from telling the patient what
to do, to asking her to go on, to giving praise. As the
therapist ceases to use imperatives, it looks as if she is
ready to discuss with the patient or negotiate whether to
continue or not. The style of the therapist’s talk has
shifted from giving instructions and feedback to having
features of the style of making conversation, but it is
questionable whether the underlying urge--to continue until
the shoulder has loosened up--has been altered or not.

A conclusion about the therapist’s talk is that it is
to a large degree instructional. The use of imperatives,
and the fact that more than twice as many functional units
are uttered by the therapist, strengthens the impression of
the therapist being in charge during the hands-on phases.
In contrast to the therapist’s "instructional" talk stands

the patient’s "conversational" talk to which we now turn.

' s S e
It needs to be stressed, again, that the patient is
seldom requested by the therapist to respond in words.
Rather, her responses are to be non-linguistic. Apart from
complying with the instructions she is given, the patient
also talks.

The eryle of the patient’s talk has been categorized

as, solely, to be meking_ccnyereericn (see Table 4.3). The
fem of her talk is mostly W. The

170

comments she offers occur throughout all phases, except in
hands-on II and hands-on VI (see Figure 4.2). The patient
brings up one issue after another, and all but one circle
around the same theme--the shoulder. In addition, the
patient responds to what the therapist says in every phase.
It is important to examine the ccnrenr of the patient’s
talk--how she talks about her shoulder, what she has to say
about her condition—-for several reasons. First of all, she
talks a lot about her shoulder, but does so in brief
sequences. Second, the therapist has not asked for this
information, so what the patient brings up can be thought
of as voluntary information. Third, it reveals something
about how the patient experiences her condition, and about
her knowledge. The therapist’s replies might function as
encouragement for the patient to go on talking or the
reverse.

The finncricn, intended and/or unintended, of the
patient’s talk is discussed throughout the remainder of

this chapter and in chapter six.

What Does the Patient Say About Her Shoulder?

When looking at what the patient has to say about her
shoulder, the impression is that she presents various
dimensions of her experience of a frozen shoulder. Her

comments can be grouped around the following concerns:

171
The present condition of the shoulder, including
when it hurts, where it hurts, and what kind of pain
there is.

Plausible explanations/reasons for today’s
condition.

The results of the ongoing treatment.
The effect upon her of receiving physical therapy.

The exercises done at home.

To be more specific, the patient states how the
shoulder feels, "It’s kind of sore." or "It’s just not
springy." She gives examples of when it hurts: "It was
tacky when I tried to open the door this morning." and
"Yeah it was real sore in class when I was lecturing. I had
I kept I had to keep rubbing my shoulder." She describes
where the pain is located and what it is similar to: "Ah.
It’s right in here. Well that’s better. I can feel it
crunching there and I can feel it move. Some stuff down
underneath it’s kind of rubbing together." She provides
plausible explanations in voicing her concern over today’s
soreness: "Maybe the difference is that it is just hard for
me to tolerate two days (of treatment) in a row." She
comments upon the result of the ongoing treatment: "Good
stretch hm?" and "It got better." She tells what it is like
to receive treatment: "Uh. It’s tiresome." She makes
comparisons between the last two days regarding the use of
a pulley at home: "Cause yesterday when I woke up. It was

just straight up. I could pull that thing down without even

172

having to reach. And this morning I didn’t stretch to

. Ah." She tells when and why she uses a weight at
home: "I do that with my weight. To stretch it over because
I feel it pull. If I can feel it pull it must be tight. So
I just practice. I do that when I watch TV." She refers to
a joke between the two about "a new word," which turns into
a lengthy discussion: "Yeah. Think of something new." Some
of these themes keep coming back.

Even if the therapist has not asked for any of this
information, each statement by the patient can be looked
upon as a reply to something the therapist mien; have
asked. Those "questions" could be formulated in the

following way:

How does the arm feel?

What do you think of the progress?

How do you interpret the lack of success?

How do you like to come here?

Why do you think the arm is the way it is today?

Do you think it is you or the treatment that is the
cause of poor progress?

How do you think coming here affects you?
What is the difference between yesterday and today?

What else do you do, apart from coming to therapy, to
maintain/increase the mobility of your shoulder?

173
The patient’s comments can also be interpreted as
prcyiding_infcrmericn to the therapist: as eigne_cfi
dieeppcincmenr with the stiffness of the shoulder: as
ettemp;§_rc_nnderernnd what has gone wrong this time: as
ingirecr_cppenie for the therapist’s opinions: as a

.2;i§igue_in_diegni§e of the treatment itself or this week’s
daily treatments. Also, to tell about how the shoulder has

reacted or "behaved" in between treatments is a way to fill
a gap in the therapist’s knowledge. By eliminating this
lack of knowledge, both will know the same thing about the
shoulder and, in a sense, be more equal. Many of the
comments can also he terms cg apology cr encnees for the
poor results of the stretchings. As reported earlier, only
two of the eighteen stretchings are considered successful
by both the patient and the therapist. In other words, the
patient seems to take responsibility for the unsuccessful
trials.

Other alternative interpretations of what the patient
says, and the consequences the answers have, will be

discussed later on in this chapter.

0 ’o s e a s

In concluding this section about therapist talk and
patient talk, it seems that "giving instructions and
feedback" represents the therapist’s dominant or primary

mode of speaking, while "making conversations" is

174
characteristic for the patient. Common to both of them is
the style "making conversation." But the therapist has in
her repertoire additional styles that can be called
registers. That is, part of her talk is strongly associated
with her occupational role, with her "doing physical
therapy."

Regarding the form of the patient’s and the
therapist’s verbal exchanges, assertions about the state of
affairs dominate, rather than questions or interrogatives.

Their secondary, or not so obvious modes of speaking,
are to be found in their replies to each other. That is,
the patient responds physically and immediately to the
therapist’s direct instructions and the therapist
acknowledges, in various ways and at different points in
time, every statement made by the patient.

This pattern does not, however, exclude topic
initiation by the therapist, as seen in Figure 4.2, or non—
verbal instructions by the patient. The term "instructions"
here refers to all the times the patient brings her arm to
a starting position without being told. By doing this, the
patient indicates that she is ready to start another
stretch and this makes the therapist resume her work. The
position of the patient’s arm can thus serve as a
proposition. Four of the seven hands-on phases are
initiated in this way by the patient. Also, the episodes of

confusion (in hands-on V, hands-off VI, and hands-off VII)

175
to be discussed later on involve several "false starts" and
deviances from the established communicative pattern.

The fact that the patient has a lot to say is not to
be interpreted as if she does not want to work or do as
instructed. It is rather the opposite. She both talks and
works. On some occasions her talk does create delays, but
so does the therapist’s. "Conversation" or talk, not work
itself or the need for prolonged recuperation time, causes
two phases (hands-on V and hands-off VII) to be longer than
all the others (see Figure 4.1).

Confirmation of the analysis of the style of the
patient’s talk and one of the functions of her talk--to
make conversation--is given in the viewing session with the
patient (Viewing session, 8/1/85). Due to various
circumstances this viewing could not be arranged until more
than a year had passed after the termination of the
treatments. The tape that was viewed was the first
videorecording (1/18/84). In some instances the patient
took a very active role in analyzing what was going on.
Three particular sets of comments are of interest: the
patient’s way of talking: how this is indicative of the
situation: and what she is trying to understand in the
midst of treatment.

The relationship between what the patient says and
what is actually happening is commented upon in the

following way:

176
It seems very clear that I’m trying to keep up
what I see as polite social interaction. All the
way through all the repee. I mean she may be
killing me but I’m trying to make conversation
.... Uh she may be killing me but, uh, if uh, you
know, it’s just unspeakable, and then I say ‘Well
gee, I should be able to do better than that or
whatever’.... I think I really do, sort of have
the sense that I’m trying to--it’s sort of like
this ‘This really isn’t, this is really just
ordinary interaction, it (the shoulder) isn’t, uh
all that sore you know, we’re going to have the
usual, uh, amenities’ and so on. (Viewing
session, 8/1/85)

Thus the patient does notice that she talks a great
deal and attributes that to attempts to define the
situation as a place to talk as well as to receive
treatment. By talking she "maintains" her posture and
refuses to let the treatment make her lose control.

The phrase "I’m trying to make conversation" is worth a
special commentary. The patient herself does not describe
her brief comments or statements as "only comments." She
spontaneously identifies them with attempts to meme
ccnyereecicn, thus referring to the function of her talk.
Although I have used the same expression in describing a
style of talk, and indirectly hinted at its function, they
together comprise, in the patient’s own words, the activity
of talking.

The expression "I’m trying to keep up what I see as
polite social interaction," is also evidence of her

assumptions about her right to talk.

177
Returning to the session on May 3, 1984 we will see

what the patient is concerned about this time.

The Theme Brought up Most Frequently by the Patient

Analysis of the content of the patient’s talk reveals
that the same issue was brought up several times. It is of
particular interest then to analyze how the therapist
responds to this and to think about what makes the patient

state the same thing over and over again. The theme the

patient brings up most frequently concerns LQQQYi§_§QL§D§§§
W- In order to understand

what the patient and the therapist make references to, a
brief summary will be given of what took place before this
Videorecorded treatment on May 3, 1984.

The patient had been seen in physical therapy for four
months, twice a week in April. On April 17, 1984 there are

discussions about taking a break.

They talk about doing nothing for one week. Then
the patient is to come every day for one whole
week for ultrasound and a stretch. ‘It might save
time and pain.’ (Fieldnotes, 4/17/84)

This trial treatment was to start on April 30, but was
cancelled due to the therapist’s temporary illness. May 1
is the first day after the break. The session starts with

the ultrasound treatment, and the patient tells of the work

178

she has done in her garden during her week off. She has
planted a dwarf cherry tree, dug 15 holes, taken care of
rose bushes and gotten lots of cuts. When the stretching is
about to start and the patient brings her arm to full
forward flexion, the therapist exclaims happily, "You
didn’t lose anything.... There are only two inches left"
(before the arm touches the table) (Fieldnotes, 5/1/84).
There are good results during this session and at the end
of the third hands-on phase, working in forward flexion,
the therapist says "Only one inch from the table"
(Fieldnotes, 5/1/84). In the progress notes the therapist
had written "US (ultrasound), stretching" (Progress notes,
5/1/84).

It is clear that the absence of treatment did not
cause the patient any decrease of mobility. Both this
session and the following one (5/2/84) are successful. The

patient is pleased.

When the tape recorder is turned off Dr. Strauss
showed me how she could move her right arm over
her head and clasp her hands behind her neck.
Very good. (Fieldnotes, 5/2/84)

The progress notes written after the treatment state
"Same as above" (Progress notes, 5/2/84). However,
something has caused the shoulder to get "stuck" again and

this is what comes up during the following treatment on May

179
3. There is also a change in the progress notes which say
"Same as above. Pain today" (Progress notes, 5/3/84).

To return to the theme brought up most frequently by
the patient on May 3, ultrasound has been given and gel has
been wiped off. With her usual "Oka::y" the therapist
indicates that the patient should bring her arm to full
forward flexion. The patient pretends to be scared or
reluctant to start the stretching in that she says "Oh.
O::hhhh" in a shivering voice. The therapist laughs. Right
here the patient begins to say that her shoulder is "kind
of sore" and a few seconds later that "It was tacky when I
tried to open the door this morning." Some minutes later,
after the second hands-on phase the therapist agrees with
the patient’s evaluation. "Stuck. Toda::y. [...] On strike.
Ya." she says while smiling (Video X, 5/3/84).

This fact does not seem to be anything unusual or
worrisome for the therapist, since she early on concludes
"It gets that way." And over the months mobility has
shifted from being increased, to remaining stable, to being
decreased (see Appendices A and I). The patient is however
bothered since she voices her concerns about the present
condition sixteen times. The patient brings this up during
phases of both hands-on and hands-off (see Table 4.4). The
therapist’s replies reported are those which are uttered
immediately after each comment by the patient. The

omittance of a period or a questionmark at the end of some

180

of the patient’s utterances indicates that she is

interrupted.

The patient starts voicing her concern in the first

phase and does not stop until the last hands-on phase is

about to begin. Is this because she talks about her worries

 

Table 4.4 Locations of the Utterances by the Patient
Regarding the Present Condition of her Shoulder
and the Therapist’s Responses

Therapist’s

Phase Patient’s Comment Reply

Hands-off I

Hands-on I

Hands-off II
Hands-on II

Hands-off III

Hands-on III

Hands-off IV
Hands-on IV

Hands-off V

It is kind of sore

Well it was

It was tacky when I
It is just not springy.
It does not go. [...]
It wouldn’t .

Two days and it doesn’t
work. Ah.

Not sensible .

 

Well it was
tender last
time.

It gets that
way.

Yeah.

Uhum.

Let’s do the
rotation and
we’ll go back
to that one.

Inaudible
response

Uh. It’s tiresome. You’re

probably tired of it

Table 4.4 (cont’d.).

Hands-on V

Hands-off VI

Hands-on VI

Hands-off VII

181

too. [.....] I think we’ve
done real
well.

It shouldn’t take

that long Interruption
by the
receptionist

Two days and maybe it

was just. I really

really stretched it

yesterday. Yeah.

Maybe the difference

is that it is just hard

for me to tolerate two

days in a row. Uhum.

Yeah it was real sore

in class when I was
lecturing. I had I kept

I had to keep rubbing

my shoulder. Hm.

Yeah I think I dread

coming on over

and then it’s harder Uhum. Harder
to let go so I
can stretch.

In fact I did some

taking up of

and I kind of jerked

it a little. The two days
we did.
Yesterday
and the day
before it just
would get real
nice.

Cause yesterday morning
when I woke up. It was
just straight up. I could
pull that thing without
even having to reach ___.

182
Table 4.4 (cont’d.).

And this morning I

didn’t stretch to .

Ah [...] It doesn’t
matter to me
whether we do
it another
time or not.

Hands-on VII --

Hands-off VIII --

 

at inappropriate moments, or does it have something to do
with the therapist’s responses?

How does the therapist respond, in fact? Her responses
vary from confirming that she has been listening, either by
saying "Uhum" or "Yeah:" to answering with a full sentence:
to giving a slightly longer reply. Other reactions are to
examine the shoulder (hands-off II), to instruct the
patient to start working in another direction (hands-off
III), or to place her hands on the patient’s arm (hands-
off VI/on VI). Besides, two of the therapist’s three
initiatives to conversation (Figure 4.2), that is, the
suggestions to cease the daily treatments (hands-off VI)
and to stop the present treatment at a certain point
(hands-off VII), can also be interpreted as delayed
responses to the patient’s worries.

One must remember that while responding to the patient
the therapist at the same time carries out her professional

manual work. She gives instructions: she pays attention to

183
the physical responses she receives: she is aware of the
patient’s attempts to endure the pain: she gives feedback
and provides evaluative comments: she decides whether to
stop or to go on. To ignore what the patient brings up
would not be considered polite. The major question to be
asked about this constellation of the patient frequently
bringing up the same theme and the therapist giving
different replies is: Why do the therapist’s replies vary?
Assuming first of all that the therapist’s responses depend
on whether the patient brings up issues like this during a
hands-on phase or hands-off phase, and that it is
difficult, if not impossible, for the therapist to give a
longer response while in the middle of a hands-on phase,
one finds that this in fact is the case. Brief answers
occur only in hands-on phases. They are slightly longer in
the hands-off phases.

One particular response from the therapist deserves
attention. The phrase "It gets that way" is important for
three reasons. First, it is stated early in the treatment.
Second, it is expressed in an affirmative way. Third, it
reveals that the therapist talks about the condition in
Qfiflslel, that is, in her experience of patients with the
same diagnosis, for the condition to vary is a common
feature.

Looking at the therapist’s replies in chronologic

order, it seems that at first the therapist does not find

184
today’s soreness remarkable. From her point of view, the
shoulder was already tender the day before. It is just part
of the syndrome. In hands-off III she responds by changing
working direction. Then she emphasizes what has been good
in the treatment. After saying that the patient’ 8 shoulder
"is real functional" (hands-off VI), the therapist finally
suggests that they should stop the ongoing treatment
(hands-off VII). The patient rejects this idea, but does
cease presenting her concerns. Thus the therapist attempts
first to reduce the seriousness of the pain the patient is
experiencing, then to stress the positive results they have
achieved.

Another plausible explanation for the therapist’s
various replies is that the information the patient gives
is not needed by the therapist. It will not affect the
treatment technique. In seeking explanations, as the
patient does, she requires the two to consider the "past,"

when the ongoing treatment is geared toward the future,

toward recovery.
It is clear, however, that the therapist’s refusal to

engage in this topic has not made the patient stop bringing

it up. It rather seems as if the patient continuously is

trying to ccnyince the therapist about how disturbed she is

by the soreness, how bothered she is by not understanding
if she herself has caused it or not, how bothered she is in

not knowing whether daily treatments are too much for her

185
specifically or for anybody else. On another level, these
statements by the patient can well be apologies for today’s
difficulties in achieving a good result.

The example in Table 4.4 of how one theme is
approached by the patient and the therapist will now be
used to illuminate other characteristics of the
communication between the two.

What the therapist says immediately after the
patient’s statement is always coded as a reply, although
one could question this where a pause lasts three to five
seconds before the therapist answers. However, it can be
argued that what the therapist says represents a form of
reply which covers or responds to more than what is
"required" by the preceding statement. In hands-off V, when
the patient says "Uh. It’s tiresome. It must be tiresome
for you too." There is silence for five seconds and then
the therapist says "I think we’ve done real well." By
responding in this way the therapist gives her opinion of
the state of affairs. She also avoids saying that "Things
Iare not going so well today." Due to the therapist’s manner
of responding to larger issues, contradictory definitions
of the situation are revealed. The therapist talks about
the overall result and is pleased, while the patient is
focusing upon the present situation and is disappointed.

The therapist’s line of reasoning is on the positive

side, emphasizing progress, recapitulating why things have

 

 

186
gone well the two previous days. At the end of the session
she compares both of the patient’s arms and finds that "You
are missing a little bit less than an inch. So then
yesterday we actually hit home" (Video X, 5/3/84). She thus
"proves" that she has been right all along. The patient
takes a more negative approach throughout the treatment,

but is at the same time eager to achieve something during

today’s session.

Different Inrerpretations or End: is Qcing on

The "local topic," or one theme both participants have
in common, is namely what is happening during this
particular treatment. When it comes to evaluating the
condition of the shoulder, the patient connects today’s
status with the two previous days. The therapist, on the
other hand, extends her evaluation to include past
outcomes. The patient refers in her talk indirectly, but
continuously, to the lack of progress in today’s treatment,
while this is almost completely absent in the therapist’s
talk.

When looking in detail at how the two verbalize their
perceptions and opinions of what happens during this
ongoing treatment, the differences are obvious. Four times
the therapist asserts or states that the shoulder is not
"quite well" today. On three occasions she agrees with what

the patient has claimed all along, namely that the shoulder

 

187
today is stiff and sore. In hands-on II/off III the
therapist says, "Stuck. Toda::y." and "On strike. Ya."
Before removing her hands in hands-on VI she says, "Real
tender. You have. Yeah it’s hard then. To let go. To let me
stretch." And in hands-off VIII, after the patient has said
"It got better," the therapist agrees but adds a
qualification "Yeah. But it is tender." All three of these

evaluations are uttered long after the patient has talked

about the condition of her shoulder. The fourth occasion

occurs during the first examination, where both agree upon
a sound from the shoulder: they say "Snap" at the same
time. These evaluations by the therapist, expressed as
declaratives, function as "official" acceptances that the
shoulder is not quite well today.

Another form of agreement between the two is related
to the discomfort that is part of the critical moment. As
soon as the therapist has started to bring the patient’s
arm down, she many times rubs the patient’s upper arm or
the back of her shoulder. Without words she says, "I know
that it hurts."

Leaving the more "negative" evaluations of the
Shoulder and looking at how they talk about the positive
results, namely that the shoulder does loosen up, it proves
that they agree upon this n; rhe seme cime as in occurs.
Previously it was argued that one of the "rules" of

treatment situations can be phrased as "Something is going

188
to happen." To achieve a loosening of the shoulder is the
sign of improvement. It also confirms that the treatment
technique is reliable. How do the patient and the therapist
mark these important instances?

The therapist says, after hands-on V, "That one
loosened up quite good. [...] Not too bad." and the patient
says happily, "Good stretch hm?". After the last hands-on
phase the patient is the first to say "It got better" and
the therapist agrees. In a pleased voice the patient
repeats her evaluation and this time the therapist says
"Yeah. But it’s tender." One interpretation is that by
wording her evaluations on both of these occasions in the
way just cited, the therapist reduces the importance of the
successful outcomes.

In the last examination of the shoulder, when the
therapist compares how far the patient can bring both arms
in forward flexion, she finds that there is no longer a
difference between left and right arm. She states
"Yesterday we actually hit home." Both are happy about this
and emphasize that "That is gccc."

These instances, where the patient and the therapist
express similar opinions about the condition of the
shoulder-~be it negative or positive--represent instances
where consensus has been reached between this patient and
this therapist, even though to a large extent their

opinions differ.

 

189
When looking at how the patient and the therapist talk
about the ongoing treatment, the impression is that things
are not going well when judged from the patient’ 8 point of

view. The therapist’s statements are, in contrast,

dominantly positive (see Table 4.5) .

Table 4.5 Estimated Amounts of Comments by the Patient and
the Therapist that are of Positive or Negative

 

Character
Positive Negative
commencs comments

Therapist 25 5

Patient 4 26

 

When listening to the therapist, everything seems to
be going just fine. tev e ' s 's .
Every trial is good, whether something has been achieved or
not. No less than twenty-five statements by the therapist

have a positive content. For example, the therapist says,

Good one.
That was good.
You’re doing rec; well.

You’re reaching so good.

The two days we did. Yesterday and the day before

it would just get real nice. (P: Aha.) It
softened. (P: Aha.) You relaxed well enough that

we .

 

190
Some of these are expressed in hands-on phases, others in
hands-off phases.

Many of these evaluations, as previously argued,
function as encouragements to the patient to endure the
pain during the critical moments. Nevertheless, this does
not exclude their positive quality.

In contrast to the therapist’s appreciative comments
stand the patient’s largely negative ones (see Table 4.5).
Many of these have already been reported in Table 4.4.

Additional examples are:

It feels weak.

That’s enough.

Oh my hand.

No wonder it’s getting purple. I know that’s pain.
It hurts right in here.

But it was even sore last night.

It doesn’t feel like it’s just relaxing. It just

feels niche.

Summary

This section, about how the patient and the therapist
approach two interdependent themes, "the soreness of the
shoulder and its cause" and "the results of the ongoing

treatment," can be summarized in the following way. It

191
appears as if both address the same themes but do so out of
different perspectives.

The major differences in their comments are to be
found in the yey they talk about the present condition of
the shoulder and hey they comment upon the ongoing
treatment. The therapist refers to the condition in
general, while the patient stresses her particular
experience. The therapist ignores the poor results, does
not doubt that progress will continue, and points to the
overall good outcomes. Implicitly the therapist states "It
does not matter that the shoulder is sore today. In the
long run it will be fine." The patient is quite disturbed
and frustrated by the poor results, and does not ignore
them. Many of her comments upon the ongoing treatment can
also be seen as explanations for its lack of success.

It becomes clear that the patient and the therapist
have different criteria for what is "good." The therapist
is positive, and gives a lot of praise. When success is
reached, she does not mark it clearly. She rather uses
understatements. As every trial is considered "good," then
success can be no better. There seems to be no difference
between a trial without a positive result and a trial with
one. The patient, on the other hand, constantly reminds the
therapist that in spite of all the stretchings, little is
achieved. When the shoulder finally is loosening up, it is

the patient herself who stresses these instances.

 

192

These different appraisals of what is going on
indicate that the patient and the therapist do talk out of
different perspectives. They have different criteria for
how to evaluate the results. What is important for the
therapist differs from what the patient stresses. It is
part of the therapist’s professional role to evaluate each
patient’s performance. In contrast, the patient is not
expected to evaluate her own performance but persists in
doing so. Due to their competing definitions of what is
good and what is not in this session, there are indications
of the therapist reducing the seriousness and the value of
the patient’s experience. In doing so, it looks as if the
therapist implicitly considers the patient’s perception or
experience to be incorrect. That neither the patient nor
the therapist "hears" what the other is saying has been
demonstrated. What matters to the therapist does not seem
to matter to the patient. What matters to the patient does
not seem to matter to the therapist. This does not change.
Both persist in their attitudes. It is never clarified that
they are reasoning from different perspectives.

The following chapter will look at situations where
their different interpretations of what is going on make

them struggle to reach consensus for what to do next.

 

CHAPTER FIVE

EPISODES OF CONFUSION

This chapter is introduced with a discussion of how
participants arrive at endings and beginnings of hands-on
phases. It shows that three of the hands-on phases are
initiated by the therapist, verbally, and the remaining
four by the patient, physically. The beginnings of the last
three hands-on phases are problematic compared to the first
four. It is during the second half of the session that six
episodes of confusion occur. Although all are very brief in
time, they are considered significant for how the patient
and the therapist in this study struggle to reach
consensus. The episodes are therefore described, analyzed,
and interpreted in depth. The chapter concludes with

stating the unwritten rules governing the session.

How Participants Arrive at Endings and Beginnings
of Hands-On Phases

So far this discussion has focused on how each
stretching or attempt to loosen up the shoulder has been
attended to by the patient and the therapist. The
expression "the critical moment" was introduced at the

193

 

194
beginning of chapter four to identify the point in time and
the position of the arm where the treatment is most
effective. It is also the most painful moment for the
patient. Both the patient and the therapist are aware of
this. The balance between how much pain the patient can
tolerate, and the desirability of a good result, is
delicate. The verbal negotiation that the two engage in
toward the end of each stretching is a sign of the
importance of the moment. The critical moment can be said
to represent a "locked position." The therapist cannot
force the patient to endure too much pain, but she can ask
her in words to continue, and she can, physically, secure
this through the use of her hands. The patient can likewise
ask the therapist to stop by showing her discomfort, and
can reinforce this by saying "That’s enough." But she
cannot physically move her arm away from the therapist’s
hands.

The right time to cease each hands-on phase is thus
more or less openly discussed. But it is always the patient
who first shows the pain, then the negotiation starts.
Sometimes the therapist decides without consulting with the
as in this example from fieldnotes:

patient,

Kathy ends the treatment with saying ’That’s
plenty.’ Dr. Strauss reacted with joy. ’What has
happened? It is the first time she wanted to quit

first’....
When I put my things together in Kathy’s office,

I mentioned how pleased Dr. Strauss was. How

 

195
surprised she was that Kathy had been the first
to quit today. Kathy responded, ’Oh, it was

nothing. I who would like to go on for hours, to
get a result.’ (Fieldnotes, 4/12/84)

Even if this example illustrates the termination of a
whole session and not a hands-on phase, the comments by the
patient and the therapist are significant. They reveal that
the therapist cannot work as much as she wants to: she must
attend to the patient’s reactions. They reveal that the
patient knows that she always "wants to quit first." The
patient’s tolerance of pain determines how much the
therapist can work.

The terminations of the hands-on phases are filled
with negotiating back and forth, but the mere notion of
yerpel_negcciericne indicates that both the patient and the
therapist have access to what is going on. They can discuss
it. Even if they do not know whether they will go on or
stop, those instances are not "episodes of confusion." In
contrast, it is the beginnings of the hands-on phases that
prove to be problematic.

A comparison between the transcription and the
videorecording shows that the initiative to start a hands-
on phase can be expressed verbally or in the form of a
motion. The initiative is taken three times by the
therapist. In hands-off I, she says "Show me your right
arm." In hands-off 11, she says "Let’s do the rotation and

we’ll go back to that one." And in hands-off VI, she says

196
"Yeap. That way. Over the head." In the other four cases it
is the patient who positions her right arm in maximal
external rotation or lifts it as high up as possible (see

Table 5.1).

Table 5.1 Distribution of who Takes the Initiative to
Start a Hands-On Phase and the Type of

 

Initiative
Type of Initiative

Hand§:Qn_£hase 221251 thsieal

I Therapist

II Patient

III Therapist

IV Patient

V Patient

VI Therapist

VII Patient

 

There is no discussion about the "right time" to
start. The therapist does not ask if the patient has
recuperated well enough from the previous phase to start
another one. The patient does not say that she is ready.
Both rely on each other’s behavioral cues. How they arrive
at the beginnings of the last three hands-on phases will

now be discussed in detail.

197

How Episodes Have Been Selected

The episodes of confusion that occur all involve the
beginning of a stretch. They occur in the second half of
the treatment. There is an escalation of them: one episode
in hands-on V (but before the stretching has started), two
in hands-off VI, and three in hands-off VII.

The instances categorized or labelled as episodes of
confusion are built upon the therapist’s comments around
the theme of patients who wanted to be "in charge." They
were "hard" patients. This was expressed first in the
viewing session (3/8/84). Other comments regarding the same
theme were brought up in the viewing session of videotape X
(11/8/84). One hands-off phase turned out to be different
from the others. The receptionist came over to ask about
some patient appointments. The therapist turned away from
the patient and moved her chair closer to the receptionist.
The patient, who no longer was observed by the therapist,
put both arms down on her stomach. When the receptionist
left, the therapist turned towards the patient again and
rolled her chair closer. When the therapist had returned to
her treatment position, that is, close to the patient’s
arm, the patient started to "warm up." She lifted, bent and
stretched her right arm up before she placed it in position
for external rotation. When the therapist saw this on the

‘video, she exclaimed "She isn’t even ready when I am"

198
(Viewing session, 11/8/84). The therapist obviously thought
that the patient’s timing should have been better. The
patient should have warmed up before the therapist was back
in her treatment position. The therapist should not have to
wait.

Later on in the same viewing session the therapist
discovered that the "patient is in control," that she
herself could "do nothing" if the patient was not ready:
"Nothing can be done till the patient decides" (Fieldnotes,
11/8/84). In other words, the patient’s arm must be in the
proper position for the therapist to carry out her work.
The therapist saw how her work was held up by the patient
and was quite astonished by this: "I who think I should
have more control" (Fieldnotes, 11/8/84). In a sense the
therapist realized that she alone does not control what
happens, that if work is to be carried out, both of them
have to be in agreement on what to do, when to start, when
to stop. What the therapist did not see, however, was that
the patient’s readiness to work was ignored by herself on
other occasions as she kept on talking.

With the therapist’s comments as a starting point, six
instances that reveal some confusion have been localized

(see Table 5.2).

199
SW
All episodes are instances of "disagreements"
regarding W: W
in: W: or men—to
start_!2rking (see Table 5.2).

Table 5.2 Overview of Episodes of Confusion.
Identification of who Displays Readiness to Work
and the Issues of Disagreement that Contribute
to the Confusion

 

 

Qispley or
Readiness—t2 lessee:
Episcde Work 'sa eemen
E 5:1 ' Patient When to start
E 6:1 Therapist Which direction
and patient to work in
E 6:2 Patient When to start
E 7:1 Patient Whether to continue
or not
E 7:2 Patient When to start
E 7:3 Therapist From which position
to start

 

Three of the six instances are directly related to
when to start: another two are indirectly related.
Originally these instances were perceived py_me as moments
of highly unsynchronized behavior. When the patient was
ready to work, the therapist kept on talking. When the

200
therapist was ready to start, the patient was busy telling
and showing where the sore spot was. Since the patient and
the therapist never L513 about when to start, problems are
likely to occur here. They do not talk about it when things
have gone wrong, either. However, their mutual awareness of
something gone awry is seen in their laughs, gestures,
repair work or face-saving activities. This concerns
particularly the episodes 6:1 and 7:1. In other instances
only one of them might be aware that something has gone
wrong.

In this analysis I take the position of an outsider,
identifying, observing, and describing instances of
sometimes very subtle communicative misunderstandings. As
the literature in the field of physical therapy is mostly
concerned with the intentional speech of the therapist and
of the patient, it is of value to shed light on other
elements that play a part in each physical therapy session.

One finds here the sophistication of multilayered
communication: an indirectness in speech which works well
under certain circumstances but goes wrong in others: and
an established pattern of communication that, when
disrupted, can cause problems. The episodes are described

in detail below.

201

Description and Analysis of the Episodes

W
The_thera2ist_talks_ab2ut_a_IY_er29ram_and_dees_net
n t' e h ' 's ead t st wo

(Hands-on V).
At the beginning of hands-off V, Rhonda, the

receptionist, enters the treatment booth and talks to the
therapist about some appointments. As they talk, the
patient keeps her arms still. When the conversation is over
the therapist turns towards the patient and rolls her chair
closer. The patient starts to warm up before she places her
arm in full external rotation as follows. The patient has
brought her arm out to the side, level with the shoulder.
There is 90 degrees flexion in the elbow, so the direction
of the lower arm and the hand is toward the ceiling. By
moving the lower arm toward the wall behind her head, the
patient increases the external rotation in the shoulder
joint. During the stretching, the therapist always has her
right hand on the patient’s upper arm and gives resistance
*with.her left hand against the patient’s lower arm.
Returning to the episode itself, the therapist now
puts her right hand on the patient’s upper arm and
stretches her back. As she starts saying, "Well," she
slumps. The moment after the therapist has relaxed her

back, the patient rolls back on her left side slightly. The

202
therapist continues her sentence and says, with laughter in
her voice, "The tune that goes through my head is ‘This is
It’" (she sings the tune). She continues, "You know that
half an hour program," and the patient asks, "‘This is
It’?". They continue talking and the patient seems to
associate the title of the TV program with the goal they
are working toward, namely, full external rotation, in that
she says, with laughter in her voice, "This is it. Crunch."
while slapping her lei; arm into full external rotation.
While the therapist laughs and continues to talk, the
patient brings her left arm down on the table and brings
her right arm into maximal external rotation. This is the
first time of the rnree rimes she indicates that she is
ready to work (see Time Schedule below). On one of these
occasions, the therapist is looking away so she cannot see
what the patient does. Finally the patient says "I’m gonna
hang on there" and grabs hold of the table with her left
hand. The therapist encourages her "Yeah. Go on." and the
patient brings her arm into full external rotation. Ten
seconds later the therapist puts her left hand on the
patient’s lower arm to give resistance. Almost a whole
minute passes before the work starts. The time schedule

looks as follows.

At 29:54 Rhonda thanks the therapist and leaves.

At

At

At

At

At

At

At

At

At

At

At

29:55

29:59

30:01

30:03

30:15

30:18

30:26

30:34

30:39

30:42

30:52

203
P starts to warm up in that she bends and
stretches her right arm toward the ceiling,
then abducts it (during silence).
P’s arm is in position.

T puts her right hand on the lower part of
P’s upper arm.

T starts talking "Well the tune that goes
through my head."

P brings her unafflicted arm into full
external rotation, as a joke, then she
brings her right arm more into external
rotation.

P brings arm more into external rotation,
the therapist looks away.

P moves lower R arm horizontally.

P brings her arm into external rotation
again.

P says "I’m gonna hang on there."
T says "Yeah. Go on."

T says "O::kay" and puts her left hand on
P’s arm for resistance.

Anaiysis of E 5:1

This is one of the instances the therapist pointed to

during a review session. She reacted to the fact that the

patient was not ready. Her comment shows a slight annoyance

‘with the fact that the patient was not about to start

‘working at the same time as the therapist. The episode

identified is, however, the minute during which the

therapist herself does not notice that the patient is ready

204
to start the stretching, and that her trials to get the
therapist’s attention about this are unsuccessful.

Why does this happen at all? No major delays had
occurred prior to Rhonda's entrance on the scene. Is
Rhonda's presence creating a severe interruption in the
work the patient and the therapist are engaged in? Does she
break the communicative pattern the therapist and the
patient have established? The therapist does talk in a
different way with Rhonda, with whom she has another
relation, than with the patient. It is the only time during
this session that the therapist brings up a topic that is,
not related to the shoulder. It is also one of the three
instances which have been categorized as therapist-
initiated conversation (see Figure 4.2).

One plausible explanation for this confusing moment is
that when the therapist talks about something, she does not
observe what the patient is doing. Her attention is no
longer focused on the patient’s arm. Also, the therapist's
deviation from giving instructions, and turning to making
conversations or story telling, breaks the rhythm the
patient and the therapist have been used to in their
special way of communicating. This makes it harder for them
to resume their work. It is assumed here that only the

patient is aware of the dilemma described.

(Hands-off VI).

The therapist nods and says "Yeap. That way. Over the
head." When saying "Over the head" she points toward the
wall behind the patient's head three times. The patient
puts her arm in position for external rotation, but the
therapist immediately says "No." The patient quickly rolls
back on the left side of her back, which has been slightly
off the table, and puts both hands on her stomach. At this
moment the therapist demonstrates forward flexion, that is,
the direction she wants the patient to work in, by lifting
her own right arm in front of her, and reaches the maximal
position. But the patient does not see this as she has
turned her face away from the therapist and has closed her
eyes. The therapist slaps her right hand on the table, the
patient says "Blah" and sighs. The patient adjusts her head
on the pillow, moves it closer to the therapist, then she
slaps both arms on the table and sighs again.

In order to clarify this misunderstanding it is
necessary to look closely at what happened prior to this
moment (see Appendices G and H), but also to see the
connection with something else that took place early in the
session. During the last part of hands-on V (external
rotation) the patient rejects the therapist's proposition

about going on with another stretch. She whispers "I think

206

I just wanna stop." The therapist accepts this in saying
"Okay. I'll hold it right there." But before she brings the
arm down, she gives it an extra push. The patient grimaces
with pain. The therapist says, "That was good" and starts
immediately to rub the patient’s upper arm with her left
hand. She then gradually moves her chair closer to the
patient's head and turns the comforting strokes into an
examination of the back of the patient’s shoulder. To her
question in the utterance "Not hurting that bad? Yeah. Not
hurting that bad right there." the patient responds, now in
a normal tone of voice and not until the therapist has
completed her utterance, "No it's not in the back. It hurts
more up here." while touching her upper arm. The therapist
then says "That one loosened up quite good. [...] Not too
bad." before removing her hand from the patient’s back. The
patient exhales and says happily, "Good stretch hm?", which
the therapist confirms, saying "Uhum. Tough one." During
the following ten seconds of silence the therapist
scratches her wrist and the patient moves her right arm
before the therapist says "Yeap. That way. Over the head."

The patient makes no complete stretch but brings her right
arm toward the ceiling, bends the elbow, stretches toward
the ceiling keeping the arm straight, and then moves it
very slightly towards the wall behind her. She sighs, puts
down the upper arm on the table (90 degrees at elbow), and

sighs again. She slaps her elbow on the table once more and

207
the therapist smiles. The patient sighs and turns her face
toward the therapist. There is one second’s pause, then the

therapist nods and says "Yeap. That way. Over the head."

Anél¥§i§_fi_§il

This episode is an example of a misunderstanding
regarding which direction to work in. Both the patient and
the therapist have seen that a mistake has taken place and
seem slightly embarrassed. The patient says "Blah" and
sighs deeply. The therapist is doing some repair work in
that she initiates a new topic for conversation. She starts
talking about taking another break in the series of
treatments.

Why did this confusing moment happen? The therapist
attends first to the pain that the stretching caused the
patient, in that she strokes her arm. Then she goes on to
an examination and with her question brings the patient’s
attention away from the shoulder joint. She also selects or
returns to a topic that was brought up six minutes earlier.
.All the therapist does can be interpreted as distracting
the patient, so that the pain will be forgotten. It also
gives the patient a chance to recover from the discomfort.
Relief can be signalled through the return to a normal tone
of voice. In this instance, the patient is able to talk

normally quite soon, indicating that the therapist did not

208
misjudge the length of the critical moment the patient
could endure.

Not until the brief examination is over does the
therapist judge the outcome of the previous hands-on phase.
She omits mentioning anything about the consequence of this
successful outcome. She does not say explicitly, "Since we
finally accomplished something in external rotation, we can
leave that and go back to forward flexion," even if this is
likely to have been her reasoning. Also, through the
examination two features are obscured. First, that a goal
with the treatment has been obtained, namely something has
happened with the shoulder. Second, by slowly moving the
chair she is sitting on, the therapist can better examine
the back of the patient's shoulder, but she also positions
herself for working in forward flexion. This postural
message is obviously not perceived by the patient (see
Figures 5.1 and 5.2).

The therapist’s word "Yeap" can be interpreted in two
ways. It can mean "Yes let's start again," but it can also
be an answer to the patient’s moving of her arm in the
direction of forward flexion a few seconds earlier. In
other words, the therapist might have assumed that the
patient knew that forward flexion was now to be returned
to.

The topic the therapist brought up, "where it hurts"

or "the sore spot," is appropriate in the sense that it

209

 

 

 

 

 

 

 

Figure 5.1 Working Position, External Rotation
(Video X, Hands-on III, 5/3/84)

 

 

/‘ Y,
I ;

 

 

 

 

«Q;

Figure 5.2 Working Position, Forward Flexion
(Video X, Hands-on I, 5/3/84)

 

210
connects to something briefly talked about six minutes
earlier. That time, as this time, it is not clarified
exactly where the pain is located. The incompleteness of
this topic has consequences later on as it is involved in
additional episodes of confusion.

The misunderstanding that has taken place here is not
being talked about. It certainly looks as if it is the
patient who has done something "wrong," but it could be
interpretated rather that both had different opinions or
assumptions about the consequences of the successful
stretching in external rotation. The patient, who had
initiated both hands-on IV and V (see Table 5.1) and had
not been questioned about them, does not realize that the
success of increased mobility at this time means that for
the therapist there is no purpose or need to continue
working in that direction.

The following episode consists of several
misunderstandings or misreadings. It is directly related to
the previous one, and builds upon the notion that the
patient and the therapist are aware of the mistake that
took place. Instead of talking about it, the therapist
brings up another topic, namely to eventually change the
series of treatments. The conversation that takes place

between the two will be quoted.

EEi§2Q2_§iZ
, , . - .. - ., , ,. ..- , ,1 . , e
,- ., '-. ,. .- ,- aqu 1 eQS't ., . o1 . a -x 01
fgr_1§_§gggnd§ (Hands-off VI).

The patient has slapped both arms on the table and

sighed, when the therapist says:

T: You do good with rest in between. I was thinking
that maybe we should do. (T hits three times on the
table with the side of her right hand) I don’t wanna
you to stop you.
P:'Yeah. No I know.

T: What you can do. You can
look at your shoulder and see it's real functional.
It's okay. You can use it the way it is. We can

P: eah.
build up the strength . But I still think that
we. You g9 good with rest in between. And if you

P: eah.

check in once a week and if each time it’s going
further then we can see. That doesn't. But you

P: eah. P:
shoulder is functional. It’ll be okay 0 get a ound
for you know for.

P: Yeah. Two days and maybe it was just.
I really really stretched it yesterday.
T: Yeah. That's
good. It really looks better than when we started
P: eah.

out. Let me get it out to the side. Is that painful?

At that place? You do better at this one?
P: Yeah.

The second time the therapist says "You g9 good with
rest in between" she leans forward and puts her right hand
on the table. As she goes on to say "And if you check in
once a week etc.," the patient brings her arm to full
forward flexion. This happens at 33:27. The therapist

continues to talk. The patient keeps her arm in the same

212
position and it is not until 33:45, that is, 18 seconds
later, that the therapist puts her right hand on the
patient's arm to give resistance. The therapist's placement
of her hand occurs in the middle of the sentence "Yeah.
That’s good. It really looks better [hand on] than when we
started out." The topic is now changed to an evaluation of
the patient's mobility. The patient does not respond to the
therapist’s indirect suggestion of when and how many times
to meet next week. She concludes the therapist's talk by
saying "Yeah. Two days and maybe it was just. I really

really stretched it yesterday." ‘

Analysis E §§2

The first misunderstanding is that the patient reads
the therapist's leaning towards her and her putting of her
right hand on the treatment table as an indication to start
working. So, the patient brings her arm to full forward
flexion. The second problem is that the therapist does not
stop talking (does not see that the patient is ready). The
third difficulty is that the therapist does not receive an
answer from the patient.

This long monologue by the therapist has previously
been categorized as an "initiative to conversation" (see
Figure 4.2). It has also been considered as a delayed
response to the patient's comments about her sore shoulder.

An alternative interpretation is that the therapist is

213
getting ready for, or is foreshadowing, the close of this
session by giving a summary. It is unclear whether the
therapist is asking the patient something or just giving
her own opinions. For whatever reason, the patient does not
give an answer.

Again, as in episode 5:1, the therapist does not or
cannot pay attention to what the patient is doing when she
herself is talking about something and is not giving
instructions.

In looking at the content of what the therapist says,
one finds that it starts with an evaluation of the
patient’s reaction to rest and to treatment. It contains
justifications for the suggestion of taking another break:
"I don't wanna you to stop." Twice the therapist says that
"You do good with rest in between." Five times she states

that the patient’s shoulder is functional:

What you can do. You can look at your shoulder and see
it’s real functional.

It’s okay.
You can use it the way it is.
But your shoulder is functional.

It'll be okay to get around you know for.

There is also an indirect suggestion from the therapist

that they should meet once a week "And if you check in once

214
a week and if each time it’s going further then we can
see."

The patient agrees with the therapist’s statements
about the condition of the shoulder but she does not
respond to the suggestion of changes. As reported earlier,
the previous week’s break had not caused any problems.

It is clear that the therapist has been attentive to
the patient's comments throughout the session about today's
soreness and its cause. Her sincere answer might be this
indirect one. The monologue can thus be interpreted as an
answer and a suggestion at the same time. The indirectness
of the speech adds to the confusion.

It is important to emphasize that the patient treats
the therapist’s comments just like the therapist has
handled hers. That is, there is confirmation about having
heard something but rarely is a direct answer provided. The
treatment itself, with its particular vocabulary, can be
thought of as competing with ordinary conversational
patterns.

The last three episodes all occur during hands-off VII
and are interrelated incidents. Ihg_f1;§§_gng has to do
with the patient, who after having rested is again ready to
work, but is instructed to rest a little longer. In thg
ggggng_gng the therapist indirectly instructs the patient
to place her arm in a painfree position, but the patient

keeps looking for a position where pain is present. Here

215
the therapist is ready to start working, but the patient is
occupied with talking about and looking for the sore spot.
In tng_;hirg_gpi§ggg the therapist misreads a gesture by
the patient. A particular position of the patient’s arm is
perceived by the therapist as an invitation to start
working. The therapist is just about to put her hands on
the patient's arm, when the arm is brought to the proper

starting position, that is, full forward flexion, by the

patient.
Episgde 7:1
c su ests to
" 9-51 9‘ '1tie _-'- s as! 9 ',. ger
e s s 05' ons e s s-
on phasg. thgn says "Take anothgr minute t9 :gst" (Hands-
off VII).

The therapist leans her head, looks at the patient and
says "It doesn’t matter to me whether we do it another time
or not. Because I think we might not get all that. Thinking
to relax . If not we’ll just schedule another
time." "Oh you mean right now or tomorrow?" the patient
asks. When the patient has said "right now" the therapist
inserts "Yeah." To the patient's "or tomorrow" the
therapist responds "Yeah forget tomorrow." The patient
answers immediately "Okay. Well. Let’s try it one more

time." During this statement there is eye contact and

216
nodding. Then the therapist says " _____. Today? Okay. Take
another minute to rest." The patient goes "Ah."

The therapist utters the word "Today" with a rising
intonation as if she is truly surprised; she then says
"Okay" with a falling intonation and moves closer, her back
already straight. Right here the patient brings up her
right arm to forward flexion. The therapist puts her left
hand on the table, then slumps and says "Take another
minute to rest." The patient says "Ah" with a grimace of
pain and brings her arm quickly down. The therapist laughs
and the patient says, "It’s right in here where it is
[...]" while touching the upper part of her right arm.

What preceded this episode? The result of hands-on VI
(forward flexion) is not considered a success like hands-
on V. Here, in Episode 7:1, the therapist admits that the
shoulder is "real tender" and indirectly attributes lack of
success to that. The therapist says, "Real tender. You
have. Yeah it's hard then. To let go. To let me stretch."
The patient agrees with "Aha" twice. Before the therapist
has removed her left hand from the patient’s arm, the
patient says "Yeah it was sore in class when I was
lecturing. I had I kept I had to keep rubbing my shoulder."
Then the patient states that she dreads coming over. The
therapist ascertains how the two previous treatments had
gone: "It just would get real nice. (P: Aha.) It softened.

(P: Aha.) You relaxed well enough that we [....]".

217

The patient agrees with the therapist's first two
statements but disagrees with her indirect way of keeping
the patient as a person responsible for being able to relax
or not, in saying "It doesn’t feel like it's just relaxing.
It just feels "tight." The patient talks about the
difference in the shoulder she had experienced in using the
pulley yesterday morning and today, and sighs deeply.

Right here the therapist proposes very indirectly that
they should stop: "It doesn’t matter to me whether we do it
another time or not". This, in turn, is quickly rejected by

the patient.

s's °

Why does the therapist instruct the patient to rest?
Judging from the intonation, the therapist seems unprepared
for the patient’s willingness to "try it one more time."
She might have assumed that the patient now was satisfied
with today's treatment. Or she might want to terminate the
session herself. The way the therapist formulates her
proposition is indirect and ambiguous when put in relation
to the patient’s questions. This proposition is similar to
the summary in E 6:2. Episode 7:1, too, can be a delayed
response to the patient's reasoning around the cause of
today's soreness, as the therapist with "Forget tomorrow"
shows that she has already decided that there will be no

treatment the following day. From the patient’s rejection

218
of the therapist's suggestion, one can conclude that even
if the patient had complained repeatedly about the
stiffness and demonstrated that each stretching had been
painful, those messages were not to be interpreted as a
signal to the therapist to stop or make the ongoing
treatment short. Also, forward flexion has not been
extended today. This was the third attempt and the patient
might not be pleased with success only in external
rotation. The therapist seems to have forgotten that no
progress was made in forward flexion. Here it is the
patient who is pushing for something to happen.

As in E 6:1 both the patient and the therapist are
aware that another mistake has taken place. Both seem to be
embarrassed. The therapist laughs and the patient quickly
returns to an old topic, "the sore spot." The patient had
been ready to work, but was instructed to rest. She had
been resting for 1 minute 13 seconds. Now it takes another
2 minutes 33 seconds before the therapist puts her hands on
the patient's arm and they start working. This hands-off
phase thus becomes the longest and lasts for 3 minutes 46
seconds. Other factors that play a part are that the two
have a long conversation about a new word and that there is

confusion about wngn to start the next stretching.

219

ts t t o

'! .'. 9‘ '1 ‘1 11‘ ’1,,,, -. ,,,‘ O ! !‘. 2'
MW (Hands-off VII)-

After having joked about how to make the shoulder
muscles relax, the topic is concluded with the patient’s
statement "It reminds me too much of lightning." The
patient brings her arm to forward flexion. She lifts her
head slightly off the pillow, blinks, makes a grimace of
pain. She puts her head down, moves the arm to further
forward flexion, says "Ah" and makes another grimace of
pain. The therapist, while showing forward flexion herself,
now says, "Sometimes it's finding the right spot we can go
back and." The therapist demonstrates the movement in the
following way. She lifts her right arm in front of her,
stops at shoulder level, and bends her elbow. Then she
brings the elbow backwards so the arm is now abducted, and
from that position she lowers her arm. She moves closer
toward the patient and stretches up. Instead of finding a
painfree position of the arm in forward flexion, the
patient abducts her arm and, while making half a circle,
brings it slowly down to her side. She is thus imitating
the therapist's movement. While doing this the patient

says, in one breath-group, "Yeah this is what I when I pull

220
it rea::lly." The therapist fills in "Feel it." The patient
agrees.

As the patient starts making the half circle the
therapist has to make room for the arm. She thus curves her
back and rolls slightly away from the table. The patient
now says, while looking directly at the therapist, "Ah.
It’s right in here" and touches the upper part of her right

arm.

na '5 E °

The therapist indirectly instructs the patient to get
ready to work now. Her phrase "Sometimes it's finding the
right spot," uttered when the patient already has placed
her arm in forward flexion but at the same time is
revealing some discomfort, can be interpreted as a reminder
for the patient to find a starting position that is up;
painful. This is the ground from which all stretchings
start and the patient knows that. Either she does not hear
what the therapist says, or she has simply not concluded
the topic "the sore spot." "The right spot" for the
therapist means, on this occasion, a painfree position, but
"the right spot" for the patient is the place in her upper
arm where it hurts.

The topic "the sore spot" is introduced early in the

treatment. The patient is the first to bring this up. It

221
happens in hands-on IV before the stretching has started.
Without saying a word she touches the upper part of her
right shoulder and makes a grimace of discomfort. In asking
"Is it tender there?" the therapist makes this an
"official" topic . As reported earlier, the therapist comes
back to this during hands-on V, when she does the brief
examination of the back of the patient's shoulder, saying
"Not hurting that bad?". This was part of E 6:2.
Immediately after E 7:1 the patient brings this up again,
saying "It’s right in there where it is." But not until now
(hands-off VII) can she say or inform the therapist exactly
where it hurts and at which position of the arm the pain is
reproduced.

From this one can conclude that it is important for
the patient to tell the therapist exactly where it hurts.
It is also a topic both can safely return to.

It is worth noting that the therapist, in this
instance as in many others, demonstrates in which direction
they are going to work. This is not new information for the
patient. The therapist's demonstrations are a silent way of
urging the patient to get ready. The therapist never says
"Please, hurry up" or "Get ready." She cannot exert any
control over the patient’s arm during phases of hands-off.
The therapist’s demonstration of forward flexion this time
deviates from her usual manner. Most of the time she simply

lifts the arm in front of her as high up as she can and

222
then brings it quickly down the same way. Here she goes
only halfway, and even lowers the arm in an unusual way.
The patient's imitation of the half circle can be
interpreted as a sign of her attention to what the
therapist did. She might have read this deviation as an
implicit instruction.

Finally, the fact that the patient does not place her
arm in forward flexion could also be an indication that she
is not quite ready to start yet or does not know when they
will start. Three times she was ready to work before but
was "corrected" (E 6:1: E 6:2; and E 7:2). So it might be
difficult to know how to properly interpret the therapist's

words and gestures.

Episode 2;;
Eng rherapist gannor get hold of :2; parienr’s arm

(Hands-off VII).

The patient continues talking about the sore spot "Ah.
It’s right in here. Well that’s better. I can feel it
crunching there and I can feel it move." She shows it with
both hands in the air. Here the patient makes some kind of
joke with her arms. With her right arm close to the table,
flexed more than 90 degrees at the elbow, the patient flaps
her right hand at the wrist while at the same time slapping
her left hand on the table. She turns her head towards the

therapist, miming a "hopeless" look on her face. The

223
therapist smiles. The patient turns her head and again
faces the ceiling. The therapist moves closer, ready to put
her hands on the patient’s arm. The patient, who does not
see this, goes on lifting her arm to full forward flexion,
so the therapist misses the arm. She then says, "Which spot
do you want? 129 pick out the spot you think is gonna do

best." Not until now does the stretching begin.

sis 7:
Why does the therapist miss the arm? Why does she
interpret the patient's gesture as an invitation to start
the stretching? Several of the criteria for starting a

phase of stretching are fulfilled.

The arm is still.

Eye contact has been established and disengaged.
The previous conversation is finished.

The patient knows what direction to work in.

But the arm is not in full forward flexion. Is the
therapist so eager to start working that she has forgotten
that during this treatment the patient always brings her
arm to full forward flexion herself? It was only during the
first weeks of treatment that the therapist assisted the
patient in lifting the arm. Also, the therapist could be

eager to start working as this hands-off phase has been

224
prolonged by conversations and uncertainties about when to
start.

During this phase the therapist has indirectly asked
the patient to get ready to work several times. This is the
third attempt. Not until the therapist assertively utters
the phrase "Which spot do you want You pick out the spot

you think is gonna do best" can they start working.

Summary

The episodes are all related to the beginnings of the
last three hands-on phases. They involve several false
starts, with the actual beginnings becoming therefore
postponed. In hands-off VI there are two attempts (E 6:1
and E 6:2) and in hands-off VII there are three (E 7:1, E
7:2, and E 7:3) before the patient and the therapist arrive
at a proper beginning.

It is important to note that the patient, in four of
the six episodes, is the first one to display her readiness
to work (see Table 5.2). When the work is delayed, it is
easy to assume that the patient has done something wrong.
But on two of these occasions (E 5:1 and E 7:1), work was
about to begin but the therapist changed her mind. The
other two (E 6:2 and E 7:2) can be labelled
Inisunderstandings, that is, reading instructions into

gestures that were merely accompanying the therapist's

225
talk. In E 6:2 the patient believes the therapist's leaning
forward and bringing her arm toward the table to be an
indication that work is now to begin. In E 7:2 she
interprets the therapist’s motion with her own arm as an
instruction to do the same.

Of the remaining episodes (E 6:1 and E 7:3) one might
claim that the patient does not read the therapist's
postural shift as an instruction when she should have done
so (E 6:1). And in E 7:3 the therapist confuses a gesture
by the patient with a signal to start a hands-on phase.
Obviously, in all the episodes, except E 7:1, there are
faulty interpretations of movements or positions.

In addition to analyzing this "physical discourse," it
is helpful to look at the impact of the verbal
communication, as an eventual source of or contribution to
the troublesome moments. When looking at Figure 4.2 one
finds that those phases where the episodes of confusion
take place (hands-on V, hands-off VI, and hands-off VII)
differ significantly from the other phases. The only time
an examination is carried out during a hands-on phase is in
hands-on V. And, as reported before, with examination goes
a particular set of questions. Instructions, which are part
of each hands-on phase, are given in hands-off VI and
hands-off VII. This happens in only two other hands-off
phases. But the outstanding feature is that the only times

the therapist herself takes an initiative to conversation

226
occur in the phases of troublesome beginnings. The
therapist's pattern of giving instructions and
participating in the conversations the patient initiates is
thus broken.

This change is first triggered by the receptionist who
enters to get some information (hands-off V). After Rhonda
has thanked the therapist and left, the therapist does not
give any verbal instructions before she introduces the
topic "a TV program." Therefore, it can be claimed that an
ordinary break such as another staff member asking for some
information can have serious consequences. One
interpretation is that Rhonda's entrance makes the
therapist leave her therapeutic role and display the
administrative side of her profession. In starting to talk
about a TV program, the therapist abandons her professional
role completely. The patient's phrase "I’m gonna hang in
there" is what turns her back into a therapist.

The second time the therapist's instructional talk is
temporarily abandoned is in hands-off VI. Here the fact
that the patient and the therapist had misunderstood each
other (E 6:1) came as a surprise to both of them. The
patient shows her annoyance or irritation by saying "Blah."
The therapist immediately starts to talk about something
else as if a mistake never had taken place. This talk leads

indirectly to E 6:2.

227

In hands-off VII, finally, the therapist invites
conversation several times. The first one is quickly
interrupted by the patient when she asks for clarification.
That results in E 7:1. Then another dilemma arises. For
quite some time the two had talked about other ways of
making muscles relax. As that topic is finished, the
patient brings her arm to full forward flexion. The
therapist's phrase "Sometimes it’s finding the right spot
we can go back and," which leads to E 7:2, can be a sign of
the difficulty in turning from conversation to giving
instructions on the part of the therapist, and to stop
making conversation and start performing on the part of the
patient. The patient continues to speak as if they still
were in the middle of a conversation.

The last incident, E 7:3, is the instance when the
therapist now is eager to start working and mistakes the
patient's display of a limp right arm for an invitation to
start a hands-on phase. This error forces the therapist to
return to her direct way of giving instructions in saying
with an assertive tone of voice, "Which spot do you want?
19g pick out the spot you think is gonna do best." Hands-
on VII can finally start.

To conclude, what can be learned from the description
and analysis of these six incidents? First, that the talk
that goes on outside of the physical treatment itself is

important to consider. Second, that the transitions of the

228

therapist's different ways of speaking can be problematic.
Third, the topics that run through the treatment are being
illuminated. Fourth, some of the unwritten rules that the
patient and the therapist adhere to are revealed. More
precisely, the analysis of the episodes provides
explanations for how two phases (hands-on V and hands-off
VII) come to occupy so much time. Conversation is a
legitimate cause for taking up time, and not solely the
treatment and its consequences. The complications that are
caused by the therapist’s alternating ways of speaking (E
5:1; E 6:2; E 7:1; and E 7:2) are also illuminated, and the
two topics that run through the whole session and are
attended to by both the patient and the therapist are
brought out. These are "Comments upon the treatment
outcomes" and "The sore spot." Analysis also shows that,
primarily, the patient talks about "The cause of today's
condition" and that this topic, too, runs through the
complete session. The last major topic, "Planning for the
future," is solely brought up by the therapist and is done
so toward the end of the session.

The episodes show how participants indirectly speak
about the unwritten rules that they follow, rules which can

be formulated in the following way.

The therapist can shift between giving explicit
and implicit instructions regarding when to start
a hands-on phase.

229

The patient should be ready to work at the same
time as the therapist. She should not waste the
therapist’s time. She should prepare herself for
the next stretch if the therapist is occupied by
something else, like talking to another staff
member.

The patient should pay attention to the
therapist's postural shifts.

The therapist is to select the appropriate time
for the termination of the session. In other

words, the therapist is to lead and the patient
is to follow.

The analysis shows that one or more of these rules have
been violated in six instances.

In the following chapter, the study leaves the
physico-therapeutic aspects of the session and looks at the

encounter as an educational event.

CHAPTER SIX

PHYSICAL THERAPY SESSIONS AS EDUCATIONAL EVENTS

The chapter discusses first the difficulties and the
pain a patient faces when afflicted by a sore shoulder and
how the condition itself demands of her to change and to
accept this change. It also considers the physical therapy
session as an opportunity for this acceptance to take
place, but this in turn alters the role of the therapist.
The therapist herself is assumed to act in a way that she
thinks is therapeutic. The chapter then looks at aspects of
teaching and learning in treatment sessions and ends with
describing two fundamentally important instances of "non-
learning."

Physical therapy sessions are educational as well as
therapeutic events. As a therapeutic event the focus is
primarily upon physical improvement. In addition, elements
of psychological support are inherently part of any
treatment. When considering a session educational, it is
not enough to assume that only the therapist has special
knowledge and is thus entitled to teach.

Until now this dissertation has analyzed the treatment

situation as a traditional physico-therapeutic event and

230

231
has primarily paid attention to its concrete or highly
visible activities. It should be emphasized that the
session analyzed here is one of the last in a series of
treatments that last four and a half months. The results
reported of this session have been built around the

following features:

How a session comes to be organized around a
specific diagnosis and a specific treatment.

The dialogue of which the treatment consists.

The talk that is part of, but still separate
from, the treatment dialogue.

Certain incidents, identified as episodes of
confusion, which illuminate some of the implicit

rules the patient and the therapist adhere to at
other moments of the session.

The dissertation now looks at the session with the
purpose of first identifying some actions by the patient
that might be psychologically beneficial for her. It will
identify actions by the therapist that might be indicative
of her providing psychological support or demonstrating a
broadened therapeutic attitude. The analysis starts with
the patient.

232

Psychological Aspects
of Physical Therapy Sessions

What does this physical restoration of function
require of the patient? Eirgr, she must be able to tolerate
the shift between being able to use her arm in a natural
way and being forced to guard it to prevent pain. She tells

of how she learned this the hard way:

One thing I gig find out, it didn't have to take
two or three times to g9 it, was that if I jerked
it, or moved it very suddenly, I would get a
spasm of pain that was so bad that. (Viewing
session, 8/1/85)

Thus it did not take long to learn how n9; to use the arm.
Sudden movements were to be avoided. The consequence is a
complete alteration from automatic movements to a conscious
and cautious use of the arm. Sggghg, she must be able to
endure being a patient. The patient refers to being exposed
or vulnerable in the treatment situation only very
indirectly. This was expressed when she asked the
researcher to restrict the showing of tapes. She did not
want everybody to "see when you were so disarmed, when you
were absolutely powerless" (Viewing session, 8/1/85).
Third, she must be able to tolerate progress one day and no
progress another day (see Appendices A and I) as well as

the lack of control.

233
The thing is it (the pain) starts to take over
your life. That, that’s all you can think about.
Or that, you can't, the teeniest little thing you
do, reminds you of it, so it's a bigger and

bigger and bigger chunk. (Viewing session,
8/1/85)

In spite of faithfully attending each appointment (see
Table 3.1), doing the prescribed exercises, and buying the
recommended equipment, a pulley, progress is slow and
therefore bound to be a frustrating experience. The
treatment situation itself provides an opportunity to give
that frustration a voice. The fact that the patient has a
lot to say has already been demonstrated in chapter four. A
question never answered is why this is the case. For
instance, the patient's comments or initiatives to
conversation that are uttered immediately after a stretch
can be triggered by the discomfort of the treatment. Out of
relief, the patient says something. Regardless of the
content, any expression can be a way to release tension.
Regarding the utterances that are not directly connected to
the stretch, there might be other explanations. For
example, by merely talking about a dilemma, room is given
for its gradual acceptance.

As seen in chapter four about the content of the
patient’s talk, what stands out is its repetitiveness. The
patient talks over and over again about the same phenomena.
This in itself might be a way of diminishing the weight of
the problem. Trying to describe exactly how the shoulder

234
feels, to properly locate the sore spot, and to reason
around causes of stiffness, are perhaps means of rendering
meaning to the physical experience itself.

Another dimension of the patient's talk could be a way
to counterbalance being the one who is constantly
instructed to do something. The patient does not surrender
passively to the role of being a patient, but makes sure
her voice is heard. Through her initiatives to conversation
the patient temporarily replaces the asymmetrical
relationship with a symmetrical one.

In turning to the talk and actions by the therapist,
the analysis reveals that she, too, attempts to establish a
more equal relationship. This is apparent in two recurring
situations. One is related to her questioning the patient
whether she wants to extend a phase of stretching or not.
Another one is the fact that the therapist seldom pushes or
urges the patient to get ready for a hands-on phase but
leaves that to the patient.

As the therapist carries out her physically
therapeutic work, her actions are simultaneously
psychotherapeutic. By being physically close, she is
available as a listener. The position itself lays the
ground for psychotherapeutic work. Simple as well as
sophisticated therapy can indirectly be accomplished. Some
features of the therapist’s talk that can be thought of as

beneficial for the patient are the emphasis upon positive

235
outcomes, the avoidance of marking poor achievements, and
the implicit orientation toward the future. Also, by
talking the therapist can help the patient relax. The
therapist stated this in the following way: "I can tell
whether she relaxes or not. If I distract her, she relaxes,
whereas if she talks about her problems, she tenses up"
(Viewing session, 10/25/84). This comment was not about Dr.
Strauss, but another patient suffering from the same
condition and receiving the same treatment.

Her statement reveals the problem that can arise when
the treatment dialogue comes in conflict with other
conversation. This line of reasoning could also explain
other difficulties plausibly. For instance, what is helpful
for the patient could be problematic for the therapist. The
patient might benefit psychologically from talking over and
over again about her problem but in doing so she also
could, inadvertantly, become physically tense and thus
hinder the treatment. So the therapist tries to make her
change the subject. As has been demonstrated, the patient
in this study does continue to talk about her condition.
Now, to hear the same story, albeit with slight changes,
time after time, poses particular demands on the therapist.
First, it stands in contrast to her being the "active" one,
the one who leads, the one who instructs. Second, the
patient talks about something that has already happened.

She talks about the past. And physical therapy treatments

236
are strongly future oriented. Third, to dwell on one's
problems can be perceived as wanting to maintain them.
This, too, contrasts to the purpose of the treatment which
is to eliminate or alleviate the physical dysfunction.
Fourth, to bring out the negative aspects of a particular
condition is also opposite to the therapist’s emphasis upon
positive results.

But even if there are potential conflicts because of
different orientations, that does not imply that the
patient does not benefit from the discussions. Neither does
it mean that the therapist is solely responsible for the
therapeutic effects. By talking, the patient herself turns
the situation into something more than an opportunity for
function to be restored. Whether this is consciously
intended or not cannot be concluded from the available
data. However, the notion that each session invites a
variety of experiences does persist. The following section
is therefore devoted to looking at treatment situations as

instances of teaching and learning.

Aspects of Teaching and Learning in the Physical
Therapy Session

Signs of teaching and learning in the therapy session
differ along many dimensions. They depend upon the
condition itself; whether one analyzes the first treatment

sessions or the last ones: and the definitions one chooses

237
to use. Starting out with how the patient and the therapist
explicitly address these issues, the following questions
will be asked. What kinds of knowledge do the therapist and
the patient bring to the situation? What do they need to
learn from each other? What do they want to teach one
another?

In the literature reviewed in chapter two the
therapist's professional knowledge was stressed, along with
that of her entitlement to teach. The patient is assumed to
be the learner. That the relationship also can be the
reverse, namely that the patient has particular knowledge
and something to teach the therapist, is not often
mentioned. What different kinds of knowledge do the
therapist and the patient possess? The therapist’s
knowledge is gained through formal studies but is also
arrived at through performing in the profession itself. In
other words, seeing and following many patients with the
same diagnosis provides a deepened knowledge of frozen
shoulder. What the patient knows is founded primarily on
her own experience of the condition. As such it is a direct
bodily experience. The description of a bus-ride will serve

as an example.

I remember once I tried to, I was on the bus. And
you have these things where you would push to and
I was sitting in a seat where I had to reach
behind me, just a little bit, to push on it. And
there was, I never knew when it was gonna be, go
so far. But if you went just Qne little bit past,

238

then you would get one of these incredible pain
spasms that were just disabling. And I had, I
didn't have very many of them but I learned real
well that I wasn’t gonna, I wasn't gonna move it.
(Viewing session, 8/1/85)

Apart from becoming aware of movements that one
otherwise never thinks of, this patient learned ngr to use
her arm. Being an academician, she also read some papers
which addressed the etiology of the condition.

When looking at attitudes toward teaching and
learning, both the therapist and the patient stress these.
However, what is to be taught and learned differ for the
patient and the therapist. In viewing sessions the
therapist states clearly both what she wants to teach and
what she needs to learn. The patient expresses that she

wants to learn and why this is the case.

And I like to know how things work. I like to
know what makes things happen. I like to know the
names of things. I would ask her (the therapist)
what muscle or bone or whatever because I like If
I feel if I know what things are called I have
more control over them.... When I say control I
mean, that I think I’m a very, that I would like
to be able to manipulate what is going to happen.
And my feeling is that the more I know about
everything the more facts I have, the more able I
am to make decisions that are going to help me,
make things turn out the way I want them to be.
(Viewing session, 8/1/85)

The patient does stress a strong desire to learn.

Knowing, to her, is one way to control what happens. In the

239
same session the patient stops the tape right after she has
said to the therapist "That's the trouble. It (the
shoulder) starts to loosen up and I think I can do more

than I really can do." Her comments are:

I'm always sorting through all the possibilities
.... If if there is something I don't know the
answer to I say ‘Well gee maybe it's this.’ Or I
think ‘Well but it could also be that.’ ‘Well on
the other hand it might be this.’ Or whatever,
but I do that about everything. When I don’t
really know what the answer is I--try to, kind
of, filter through and--and figure out what the
best--most efficient explanation is. (Viewing
session, 8/1/85)

In this excerpt the patient brings up several issues.
She asserts that the way she acts during the sessions is
characteristic for her. In other words, she approaches
treatment situations as she does other situations. Part of
her behavior is wondering what is happening. She takes the
responsibility to provide many of the explanations or
answers herself. Implicitly, the patient states that she
does not really seek answers from the therapist but that
she "thinks out loud" during the sessions.

According to the therapist, one of the cornerstones in
physical therapy is the education of the patient: "The
treatment is only temporary and the teaching is going to be

lasting" (Viewing session, 3/8/84)-

240

e i e d
and_flants_t2_1ea2h

The study now compares the beginning of the series of
treatments with the end. The study will look at some issues
of teaching and learning occurring during the first month
of treatments and report them in a summarized fashion.
First there will be a discussion about what the therapist
needs to learn from the patient and what she wants to
teach, then an analysis of what the patient wants to know
and what she in turn tries to teach. After this, the study
returns to the session on May 3, 1984 to see how teaching
and learning are expressed on that occasion. Finally there
will be a report of two instances of "non learning."

At a viewing session (ll/l/84) the therapist reported

that she wanted to know whether_a_natient_thiaks_nhx§igal

t ° 0 n e o :

So that I don't try to treat a shoulder when the
patient in the back of the head thinks ‘Well I
got a spur and it has to come out. My arm is not
going to get better until it comes out';

what_2atients_2922.:heut_theirinrehlem and she would ask:

Are you coping right now?
Are you doing something?
Are you taking pills?

Are you getting angry at it?
Are you doing exercises?

241

and She wanted to know h2w_the_nain_lreaets£_eut§ide_ef_the
treetmen;_eirherien: "I want to know all about them, about

the pain, how it reacts when they are not here."

The therapist wanted to teach the_rgutiae_itself_whieh
ingludes_wax§_te_relax:

One of my goals is always for them to feel
comfortable with me and with my techniques. And
that is why I describe the techniques.... That is
why I go real easy in the beginning so they learn
And they relax more and it is more fluent.... I
want them to be able not to hold back and think
they have to be quiet and keep it inside I wanted
her (Dr. Strauss) to let it out, because it hurt,
so that she can relax. Because if she keeps it
inside and thinks she has to show good
cooperation, if she tries to do all those things
she will tense up. (Viewing session, 11/1/84)

She also wanted to teach the_fun2ti2n_ef_ths_sheulder_ieiat
and wha; hinders motioh: "I want to tell how normal motion

is, how their motion is, different ways of getting normal
motion": and what_exsr2ises_t2_d2_at_h2me_and_whx_thex
ehehid_he_dehe "My work is to have them realize that they
have to work with their shoulder to get it better."

fine; the Eeriehr Wehrs to Learn and Tries te Ieeeh

What does the patient want to learn and what does she
try to teach? Her questions focus upon two things, namely

0 o i 'on m ' orse whe awa

fr2m_the_treatmsnt_§ituatien. and h2w_t2_find_ezplanatiens

242
0 .9: e 9199‘! 10 1 tr SJ--_,°.‘ ‘9‘! 1‘. ‘1 11‘!

girderieh. She asks specifically the following questions:

I guess my concern would be. If there really is
something that is pushing on the spinal column
the spinal cord. To make sure I don’t
inadvertently do something that will do more
damage. [...] Could you do an exercise and make
it worse? (Video I, 1/18/84)

And

"I’m still sleeping with my teddybear pillow under my
arm. Is it better to? [..] In other words if I can sleep
with it (the arm) down without the pillow would that be
better?" (Video V, 2/1/84). During the viewing session of
video I, the patient stops the tape after she says, during
a hands-on phase, "You can tell though. (T: Keep pushing.)
That when you do that. Then I can move it a little bit more

every time." The patient’s comments are:

I’m explaining. Doing the same thing I always dd
I think I’ve I’ve noticed something new, as my
repertoire of knowledge. So I can say ‘Aha now I
can see, that when you do that, then I can move
it a little bit more each time.’ Because it helps
explain to me why we’re doing what we’re doing.
(Viewing session, 8/1/85)

And later, on the same occasion she says, "A very
powerful theme for me is I want to know why things happen.
And why things are the way they are." Again the patient

says that she learns by seeking explanations. Also, she has

243
a strong conviction that there are explanations for
everything.

As mentioned before, the patient does not state in
viewing sessions that she has something to teach the
therapist. However, she tells/teaches the therapist heg_ehe
signale_pein: "I was brought up frontier style. You don’t
scream unless you’re dying. Actually it is better if you
don’t scream then. Oh my." (Video I, 1/18/84). She

commented upon this herself in a viewing session,

When I say ‘Oh my’ that was the worst that I’m
gonna allow myself to say. That was just exactly
like the screaming and yelling. Uh for me that is
a very very strong statement. But I mean who
would know that I mean, when you say ‘Oh my’ What
I’m saying is ‘Oh my that was just unspeakable It
was intolerable.’ (Viewing session, 8/1/85)

She also tells the therapist that she knows exactly he!
mdeh_ehe_eeh_reke: like "I really do know how mu::ch. That
maybe one little more. That’s how much is gonna be enough."
(Video V, 2/1/84). And finally, in every session the
patient tells about WW
life.

Turning to the session that has been the focus of
analysis, recall that it occurs late in their relationship.
At this point in time there is not much left to teach the
patient. She has already learned how a frozen shoulder

changes the physiological and biomechanical conditions of

244
the joint. She knows the treatment routine. The traditional
educational tasks, namely instructions regarding how to
properly use the arm, what exercises to perform at home,
and how to find positions where the arm can rest, were all
given during the first month of treatment. All the
therapist continues to teach are explenerien§_fer_1eek_ef
mehiliry: ”It’s that big muscle." It is questionable
whether her stress on the positive achievements should be
called teaching or not. One interpretation is that the
therapist, on a metacommunicative level, does recommend the
patient to "edepr my perspective. If you do you will fare
much better. Accept that you have done well, instead of
clinging to the present temporarily poor results. See the
process at large, not day by day, not moment by moment."
Thus the therapist’s emphasis on positive outcomes is an
attempt to alter the patient’s attitudes.

There is also reason to assume that the therapist now
knows the patient and her shoulder well enough, since she
asks few specific questions. In spite of this, is the
patient still trying to teach the therapist something? The
patient continues to report in great detail what living
with a frozen shoulder means. And, looking at what the
therapist said was important for her to know when seeing a
new patient (see pp. 240-241), this is exactly what Dr.

Strauss keeps saying (see pp. 171-172).

245

Signs of learning on part of the therapist are to be
found in the number of stretchings per hands-on phase she
instructs/asks the patient to do. She knows quite well now
how much the patient can tolerate. This knowledge is
inferred from paying attention to changes in the patient’s
tone of voice. Even if the patient hardly can speak at the
end of some hands-on phases, it does not take long for her
to return to a normal tone of voice, after the therapist
has lowered the arm.

The therapist also learns, at different points in
time, throughout the session, the present state of the
patient’s shoulder. Noticably, she does so quite some time
after the patient has told that the shoulder is sore, is
stiff today. This was discussed in detail on p. 168.

It is easy to outline evidence for what the patient
has learned, or rather, evidence of her knowledge. One, she
does her eyn_eyeiperiep_. She continues to make comparisons
with her unafflicted arm during the session and she reports
changes in her right arm from one day to another. Two, she
reveals her errephiyepeee_re_her_ehedider and how this
leads her to "provide treatment" herself. Evidence of this
is found in her rejection of the therapist’s suggestion to
do a stretch in the horizontal plane. The patient says "I
do that with my weight. To stretch it over because I feel
it pull. If I feel it pull it must be tight. So I just

practice. I do that when I watch TV." Three, the patient

246
demonstrates hheyiedge of how mobile her shoulder is, where
the pain is located, and she claims that poor achievement
is not due to her being unable to relax, but is caused by
tightness in particular muscles. In a sense, the patient in
this session reasons like a physical therapist herself. She
knows when to take action, how to find painful versus
painfree positions, how to judge the outcome by making

comparisons with her unafflicted arm.

Summary of Teaching and Learning Aspects
of the Physical Therapy Session

This summarized version of issues of teaching and
learning has shown that what is important to learn and to
teach for the therapist varies over time. What remains
unchanged to learn, in each session, is the status of the
patient’s shoulder. What remains unchanged to instruct is
the stretching itself, but it is rather to be considered a
repetition of a pattern than something that has to be
taught anew. What also remains unchanged are the
biomechanical explanations for restricted mobility. Maybe
one can say that toward the end of a series of treatments
the therapist’s official teaching role has given way to a
more supportive or psychotherapeutic role. The therapist
once said, when talking about teaching and learning, "Some
people, you know, need a lot of empathy and some people are

looking for information" (Viewing session, 3/8/84).

247

The fact that the therapist does learn each session
about the state of the patient’s shoulder and that she has
learned how much the patient can tolerate of the treatment
are so played down or so intertwined with the treatment
dialogue that they are hard to detect.

For the patient some aspects of teaching and learning
are to be found both at the beginning and toward the end of
the series of treatments. Regarding learning, it seems that
the patient takes every opportunity to come to grips with
or to understand why her shoulder reacts the way it does.
Every stretch is perceived as something to learn from. And
through this the patient also teaches or "informs" the
therapist about the status of her shoulder. This happens
just as much during the first Videorecorded treatment as

during the last one.

Instances of Non-Learning

Two examples illustrate where learning can be said not
to have taken place. The first one concerns expressions of
pain during treatment and the second one the patient’s
perception of what is most important to do for her
shoulder. Briefly, the therapist does not want the patient
to "grin and bear" the pain that the stretching inevitably
causes, but to express it, both in "yelling" and in words.

The therapist formulated this in the following way: "She

248
doesn’t state ‘I can’t take it any more.’ She makes noises
that are not really words to let me know that it hurts"
(Viewing session, 1/11/84). The patient, on the other hand,
states that not a word will come over her lips, no matter

how uncomfortable the stretch is.

In the hospital (after the car accident 1979)
they did some reelly awful things but I never
once said ‘Ouch.’ And kind of, you know, sort of
prehd of that ... I can take pride in the fact
that they didn’t make me yell. (Viewing session,
8/1/85)

These divergent attitudes, where the therapist wants
the patient to "let her emotions out" and the patient
herself wants to "keep them in," are expressed during
several sessions by both of them, but always implicitly. In
viewing sessions, as seen above, both commented explicitly
on this phenomenon. The therapist’s argument for asking the
patient to express freely the discomfort she feels could,
as mentioned before, be a technique to make the muscles
relax, but it could also be a wish for a more precise
verbal communication of the experience of the pain. The
therapist really asks for two things. On the one hand she
asks the patient to show what she feels, that is, to let go
of the control, but on the other hand she asks her to stay
in control by using words to express her pain. If something
hurts too much, one cannot talk. If something hurts, but

one can still talk, that is a sign that the pain is less

249
severe. If a patient uses words to communicate discomfort,
then a therapist can use words to distract her. Whatever
happens in treatment situations can be attributed to the
treatment being too harsh or the patient being too
vulnerable. To provide an optimal amount of treatment is a
challenge in physical therapy.

Evidence of the patient’s reason for non-compliance or
non-learning is that she wants to be stoic and asks the
therapist to respect this: "I was brought up to be very
stoic and not to cry" (Viewing session, 8/1/85). By
referring to her upbringing the patient states two things.
One, she has learned he; to show her emotions. Two,
whatever difficulties she will encounter, she is not ready
to change that behavior. The patient also asks the
therapist to pay close attention to her non-verbal
communication.

This discussion of the display of pain in treatment
situations is central to physical therapy. The therapist
offers the patient a place or a situation where it is
acceptable to express strong emotions. This will, of
course, have no effect upon the patient if she does not
identify the physical therapy setting as the therapist
does.

The second example has to do with the relation between
treatment provided at the outpatient clinic and the home

activities. It is related to the patient’s knowledge or

250
awareness of what would help her the most. This is
something which I asked the patient about during a viewing
session (8/1/85). The response was that she did not know.
When questioned a bit further whether recovery had
something to do with her keeping up her exercises, or using

a wand or the pulley, she said,

Well I think whatever the things I was supposed
to do at home were very clearly part of it. That
if I didn’t de them I wasn’t going to make any
progress. And that it would take longer and Lord
knows no one would want to errepd it. (Viewing
session, 8/1/85)

Thus merely to use the arm as much as possible (like
working in the garden) and do as instructed was good
enough.

From the therapist’s point of view, one particular
exercise, the use of the pulley, is the most important. In
a viewing session (3/8/84) the therapist discussed the
patient’s frustration and her own concern over the slow
progress. She wondered, "Am I ever going to get her to
reach the full range of motion" (Viewing session, 3/8/84).
The only alternative treatment would have been manipulation
under anaesthesia. But considering this only a hypothetical
solution, the therapist said with conviction, "If 1 would
be Dr. Strauss I’d be making epre I would have time to make
my own exercises more often." I said that Dr. Strauss was

quite worried. She had told me "I can get it (the arm) up

251
here, but the last part I can’t get by myself." "The

pulley," the therapist said. She continued,

She doesn’t like it though. It hurts. That’s the
one she avoids. That is the one she didn’t put up
for two weeks. When I told her about it, she
couldn’t find a place to walk it over and this
and that. (Viewing session, 3/8/84)

The therapist states that the patient does not want to use
the pulley, even though she knows how important it is. "I
have talked to her about it again" (Viewing session,
3/8/84).

When going through the fieldnotes regarding comments

upon the pulley the following four instances were found.

1. The patient "had had no time for making
arrangements for a string so she could lift up
her right arm with the help of her left. She was
going to use a hook, used for a flower."
(Fieldnotes, 2/1/84)

2. The patient reported "that she had now ordered a
pulley and that she has finally been able to
start pushing herself beyond where she actively
can’t go further." (Fieldnotes, 3/12/84)

3. "The pulley has arrived. The patient complained,
‘They are very slow.’ In the meantime the patient
had used to place her fingers on top of a door to
stretch out." (Fieldnotes, 4/3/84)

4. The patient states "Nauseating" when asked
what it was like to use the pulley. "But I
do it." (Fieldnotes, 4/10/84)

 

252

What is important to observe here is that it has taken
two months of treatment before the patient can start
pushing herself. What the therapist perceives as resistance
or non-compliance could simply be signs of the patient’s
physical and psychological difficulties.

Why is the use of the pulley such an important issue
for the therapist? And why does this go unnoticed by the
patient? One interpretation is that the therapist actually
asks the patient to carry out "hands-on phases" at home.
She asks her to keep the arm still at full forward flexion.
Her reasoning is likely to be like this: "To be truly
effective, repeat as precisely as possible the treatment I
usually give you." The patient, on the other hand, makes no
distinction between the home activities. The therapist’s
message has had no impact on her. Referring to what the
patient tells about her doings when at home, like
gardening, she indirectly says that moving her arm, that
is, imitating the "hands-off phases," is what she should do
and does when on her own. One must also remember that the
patient had learned not to use her arm beyond a certain
point. Simply to be able to use the arm as much as possible
could be more important to the patient than the therapist

is aware of.

253

Questioning the Goals of Physical Therapy

The two examples discussed above point to some general
issues or questions about goals of physical therapy. Is it
the goal of physical therapy that the patient should only
learn what the therapist considers to be most important? If
this does not take place, is the patient then non-
compliant? If a therapist indirectly says "This physical
therapy department is a special place. Feel free to ‘act
out.’ But, please, don’t lose control totally," should a
patient accept that? If a therapist assumes that her own
doings, that is, what happens during the hands-on phases,
are what get results, should a patient imitate those
outside of the treatment situation? If these prejudices are
representative of how teaching and learning are perceived
and acted upon in a therapist’s everyday practice, then
they need to be reconsidered. It is important to see the
distinction between what the therapist intends to teach,
which she has control over, and what the patient learns,
which is beyond the therapist’s control. Another step to
take is to start looking for how and when patients tell
what they have learned and how they make use of this
outside the treatment situation.

This section has considered two alternative
perspectives from which treatment situations can be

analyzed. The conclusion is that every session in itself is

254

an opportunity for the patient to restore function, to
heal, and to learn. While it is not possible to distinguish
from this study what benefits the patient most, it is
possible to identify occasions on which the patient and the
therapist reach consensus or fail to understand one
another’s goals, concerns, or definitions of the situation
at hand.

The following chapter summarizes the findings of the
study, draws conclusions from them, and outlines future

implications for practice, research and education.

SECTION III

CONCLUSIONS

CHAPTER SEVEN
CONCLUSIONS

AND
IMPLICATIONS FOR THERAPY, RESEARCH AND EDUCATION

The title of this dissertation suggests that physical
therapy can metaphorically be conceptualized as a form of
communication. As such it requires two parties to send,
receive, and interpret messages through a variety of
channels. Concretely, physical therapy sessions are face to
face encounters that take place in particular settings,
under particular circumstances, with particular purposes.
The main goal, to restore function, structures the
interaction between the patient and the therapist. Hey this
is done has been the focus of this study.

In the attempt to describe some instances of the
practice of physical therapy as adequately as possible,
this study has paid attention both to the concrete
treatment technique, used when treating a frozen shoulder,
and to the talk that evolves between the patient and the
therapist. Details of actions, both vocal and non-vocal,
were analyzed in Videorecorded sessions, as well as

fieldnotes, interviews, and documentary records.

255

256
This chapter first gives a summary of the findings
from the study, then discusses the conclusions drawn and

outlines implications for research and therapy.

Summary of Findings

First, a note on the outcome of the total series of
treatments is in order. On May 3, 1984, four months after
the initial treatment, the patient had gained full forward
flexion. External rotation was not complete until September
1984 and this happened at a gym when the patient was using
arm-strengthening equipment (Fieldnotes, 7/20/85). Thus
eight months after the treatments had started at this
clinic the patient had regained full mobility of her
shoulder. But the time from when her shoulder first started
to hurt, January 1983, until recovery, September 1984, was
20 months. When comparing to Reeves’ study (1975), where
the average time from initiation of problem to recovery was
30 months, and where no individual physical therapy
treatments were given, there is ground to assume that the
treatments given at this clinic and this patient’s ability
to endure them hastened recovery. However, this study says
nothing about which single factor or which combination of
factors that were most important. It could be the

treatments themselves, and/or the patient doing exercises

 

257
in between treatments and thus maintaining the mobility,
and/or spontaneous recovery.

The main purpose of each single treatment session was
identified as an expectation and a claim: "Something is
going to happen." Each session consisted therefore of
several attempts to loosen up the shoulder. Only a few of
them were successful. The treatment technique itself,
stretching, segmented each session into phases of hands-
'on, where the therapist and the patient physically worked
close together, and phases of hands-off, or phases of
recovery, where the therapist no longer touched the
patient.

For the treatment to be carried out, certain commands
had to be used. The therapist’s primary mode of speaking
was identified as "giving instructions and feedback." The
therapist displayed different styles of talking, and they
were found to correspond to the activities at hand, while
the patient’s singular style of talking, "making
conversation," remained unaffected by them. Thus the
session contained both a "treatment dialogue" and a special
form of "conversations." The treatment dialogue consisted
of the therapist’s use of a particular register, that is,
her verbal and physical instructions and feedback, and the
patient’s inaudible, physical responses and vocalizations.

A regierer, according to Cazden (1988) "is a

 

258
conventionalized way of speaking in a particular role, and
is identified as a marker of that role" (p. 159).

Each statement by the therapist during the treatment
dialogue built upon the physical response from the patient.
There was a continuity in this dialogue in spite of its
surface structure of being a string of commands with little
coherence.

The conversations were initiated primarily by the
patient, and the therapist became the respondent. Many
times these conversations ended quickly and were therefore
brief. These conversations, initiated by the patient,
seemed at first to be quite separate from each other, to
lack continuity. A content analysis revealed, however, that
the patient repeatedly talked about the same theme, albeit
with variations.

The two dialogues are intertwined throughout the
session. This indicates that there are rapid but subtle
shifts in the social relations between the patient and the
therapist. The therapist is at one moment someone who gives
instructions, who leads. At another moment she is someone
who is expected to respond to a statement by the patient.
Then again she is someone who is giving instructions. As
soon as the patient starts talking about something, no
matter the topic, she disrupts or violates the
interactional structure which is set up implicitly by the

therapist’s first instruction. The therapist’s return to a

 

259
new command reverts the structure again. A treatment
dialogue and a brief conversation occur separately only in
two phases each (see Figure 4:3).

These two dialogues indicate also that the treatment
situation is defined in different ways. The treatment
dialogue ascertains that this is a medieel_eyenr. The brief
conversations signify that it also is a eeeiei_eyepr.

Both the patient and the therapist "enact," that is,
act in accordance with the medical definition, but it is
primarily the patient who sustains the social definition.
Her persistence in staying on the same topic, her shoulder,
however, complicates or obscures this definition. These two
definitions, and there might be more, exist side by side.
Multiple definitions are also found in other studies of

clinical encounters. Emerson (1970, pp.91-92) states that,

Many situations where the dominant definition is
occupational or technical have a secondary theme
of sociality which must be implicitly
acknowledged.... Sustaining a sense of solidness
of a reality composed of multiple contradictory
definitions takes unremitting effort.

Particularly,

the patient’s ambition to "understand what is
really happening" may lead to undermining of the
medical definition. (Emerson, 1970, p. 95)

260

Mishler (1984) addresses similar issues but names them
the voice of medicine and the voice of the lifeworld.

As has been discussed earlier, the patient is keenly
aware of what is going on during the session. She also
tells what she experiences right then. Recalling that the
patient is a social scientist, one might assume that it is
easy for her to express herself in words, that she is more
analytic than other patients. However, the words she uses,
the events she talks about, are quite ordinary. She tells
of how she stretches her arm when watching TV, her problem
in bringing her arm all the way up when she is about to use
the pulley at home, or how she has to rub her arm in the
middle of lecturing to relieve the pain. Dr. Strauss
reasons like any other patient who is concerned about her
injury and whose life, for the time being, is "run by it."

Regarding the relationship between talk and the length
of some phases, it was found that talk itself caused two
phases to be prolonged (hands-on V and hands-off VII).
These were also the same phases in which four of the six
brief episodes of confusion occurred. In hands-off VI two
episodes of confusion took place. Shifts in the therapist’s
style of talking were present in each of these three
phases. The analysis of the six episodes identified how
four unwritten rules were violated. These rules concerned
primarily who was to lead and who was to follow. The

therapist could shift between giving explicit and implicit

261
instructions regarding when to start a hands-on phase. If
the therapist was occupied by something else, the patient
should use that time to prepare for the next hands-on phase
and not make the therapist wait. The patient should pay
close attention to the therapist’s postural shifts and read
them properly.

Returning to the content of the patient’s talk during
the session that was analyzed in detail, we saw that
whenever the patient stated something or started to talk
about something, the topic was her shoulder. The patient
talked mostly about the present soreness of her shoulder
and speculated about the cause of it. She also commented
upon the immediate outcome of the stretchings. So did the
therapist, but to a lesser degree. "The sore spot" was a
topic both referred to on different occasions, but only the
therapist talked about future plans of treatment, and did
so toward the end of the session.

Then, assuming that whatever was talked about could
carry other implicit messages, the talk itself was analyzed
anew. Although the primary responsibility for a physical
therapist is to help a patient restore function, this does
not exclude other aspects of healing. By looking first at
some psychological aspects of treatment situations, then
seeing the treatment situations as instances of teaching
and learning, the talk took on another meaning. As the

patient, spontaneously, took every opportunity to talk

262
about her shoulder, this was interpreted as a means of
coming to grips with or accepting her present status. The
mere process of talking about a problem or a concern and do
so in the presence of a listener, familiar with the problem
itself, was interpreted to be psychologically beneficial
for the patient. This, in turn, would place the therapist
in the role of a listener, where the eer_ef_ii§;epihg would
be the therapy.

As the patient would talk about her shoulder and its
mobility or lack of mobility, she would also learn more
about her shoulder joint, or discover new aspects of it.
This took place during each ongoing treatment. By making
her bodily experiences explicit, she, at the same time,
offered the therapist something to learn. And at each
session, the therapist found out/learned about the status
of the patient’s shoulder. This was inferred to be done
through her listening to the patient, through her brief
examinations, through her close monitoring of the patient
and the consequent minor adjustments in her treatment. Her
attentiveness to the patient’s signals of pain during the
hands-off phases was also interpreted as instances of

learning about the patient.

263

Issues Illuminated in This Study

Several issues have been illuminated in this study.
Eireh, there is the notion that physical therapy sessions
are interactionally accomplished. This means that both the
patient and the therapist do something all the time, and
they take account of what the other party is doing.
Scheflen (1973) says, "All participants hold postures and
facial expressions at all times and they move together" (p.
5).

To describe, for instance, the treatment dialogue as
"an audible instruction by the therapist followed by an
inaudible, physical response by the patient" points only to
the sequential/reciprocal dimension of the process of
communication. What is left out is the simultaneous or
complementary dimension. In other words, h e 'me
as the therapist gives instructions, the patient hears her
words and shows that she is listening. Although it is easy
to identify speaking as an active process, listening is not
a process of passive reception, but an activity that
involves production (Erickson, 1986a). And "Given this
interdependence, an intimate kind of conversational
cooperation is continually necessary among all the
conversational partners engaged in interaction" (Erickson &

Shultz, 1982, p. 18).

264

The eeeend issue stressed in this study is that any
encounter or any session is a local production, the outcome
of which is difficult to predict. In spite of adhering to
the same treatment routine, each session is negotiated anew
by the patient and the therapist. Anything that happened
during the ongoing session was potentially accessible to
both the patient and the therapist, but what events they
paid attention to and how they interpreted particular
instances differed between the two.

The rhird issue brought up is that of knowledge and
power. The inherent asymmetry between the patient and the
therapist is grounded on their different knowledge and
their different status. One, the therapist, possesses
knowledge in the form of medical and technical expertise.
The patient’s knowledge is of another kind. She has
experience from working in hospitals, from being
hospitalized after a car accident, and from teaching social
science. She is also, in a profound sense, experienced with
and knowledgeable about frozen shoulder. Both the patient
and the therapist reveal what they know throughout the
sessions. The patient continually displays her knowledge by
providing relevant information about the status of her
shoulder; by showing when "too much is too much": by making
her own evaluations of what is taking place in her shoulder
joint explicit; by formulating questions to herself

regarding lack of progress and then providing alternative

265
answers: and by not accepting the therapist’s claims of
good results if nothing remarkable has happened. By placing
her arm in proper position before being instructed to do
so, her familiarity with the treatment routine is revealed.
In other words, this patient trusts her own experiences.

Clearly, the patient and the therapist had the same
general goal in mind: to improve range of motion of the
patient’s shoulder. However, they had different local
moment to moment goals within the sessions. Both defined
the treatment situation as a medical event; the patient
also turned it into a social event. The therapist saw
learning as an important outcome of the treatment: the
patient saw it as a way to understand different phenomena
but also as a means to gain control over what was going on.
Both possessed knowledge which was similar as well as
different.

What were the particular consequences of the patient’s
demonstration of her knowledge? How did it affect the
ongoing treatment? Did it hamper the striving toward a
consensus, essential to maintaining an efficient work
relationship? Some disagreements or attitudes persisted
throughout the sessions. These were their different
opinions of how pain should be expressed; their evaluations
of the overall progress: when, during the treatment, they
were convinced or sure of the status of the shoulder; and

what time perspective they used. But, more precisely,

266
evidence of interactional dissonance was found when
particularly confusing moments were analyzed. Those brief

episodes revealed the following:

The patient and the therapist missed each other
physically.

They talked past each other.
They contradicted one another.

They had different criteria for judging a stretch
"good" or not.

One cause for their talking past each other can be the
fact that both, occasionally, "think out loud." That is,
what they say is not addressed to the other party, it is
more a way of having a private conversation with the
situation itself. What is displayed, unwittingly or not, is
their own way of thinking, of reasoning around what is
happening. For the other party present it becomes difficult
to discriminate whether one is being told something and is
requested to respond or react or whether one should just
keep quiet. When thinking about talk as being directed to
someone, the therapist alternates among talking directly to
the patient, talking with the patient, talking to the
patient’s shoulder via the patient, and carrying on her own
conversation with the situation. The patient alternates
among talking directly to the therapist, talking with her,

and conversing with the situation at hand.

267

The participants gave evidence of sensing this
difficulty. For example, the therapist reported early on in
the study that she was aware of some of these very subtle
problems. She thought of Dr. Strauss as a "hard" patient,
as someone who wanted to control the treatment, to "run the
show." As this analysis has demonstrated, the patient did
lead many times. She initiated several hands-on phases; she
initiated the termination of every hands-on phase: she
rejected several of the therapist’s propositions; she
introduced topics for conversations. This was obvious
particularly during the last Videorecorded session. Their
difficulties in reaching consensus did remain. The patient
implicitly and explicitly challenged the therapist’s
professional authority. To find out whether the therapist’s
impression of the patient as "being in charge" was
congruent with her own experience, the patient was asked if
she had had any "say" over the treatment. She responded in

the following way:

As to your question, I feel that mostly I was
’done to,’ that I had little or no control over
the treatments. I did know, of course, that if I
made enough of a fuss that Kathy would stop, or
shift to a new exercise--but mostly I felt that I
was a body to whom awful things had to be done.
None of the exercises (if that is what they
should be called) were generated by me, and even
if I cooperated by trying my best to do what I
was told, did things at home, etc., it still
felt/feels as if I was ’done to.’ Even knowing,
of course, that if I did not want to be crippled
I hed to be done to. (Letter, 2/13/85)

268

One finds here that the patient did perceive herself
as being "done to" with few opportunities to affect the
situation. The analysis of the data shows that this is
contrary to the therapist’s perception. One explanation for
their different understandings is that what the patient
calls "cooperation" is what the therapist considers
I'resistance." This brings us back to the issue of power or
control.

Who should be in control? The one representing the
medical establishment or the one representing her own body?
Or can one accept that control continuously shifts from one
person in a dyad to the other? Bateson (1972, p. 267)

writes,

A human being in relation with another has very
limited control over what happens in that
relationship. He is part of a two-person unit,
and the control which any part can have over any
whole is strictly limited.

Despite the fact that the patient and the therapist in
this study were knowledgable and competent people, the
fundamental difference between the two remained. And they
knew all along who was the patient and who was the
therapist. The original roles persisted and with them lack
of equality. Erickson and Rittenberg (1987) state that the
asymmetry in knowledge and power between a service provider

and a receiver of services is manifest even during the most

269
routine examination. And "That asymmetry is inconsistent
with the American ideal of equality among persons" (1987,
p. 403).

One explanation for the talk that took place is that
the patient and the therapist in different ways tried to
compensate even for this discrepancy. All the patient’s
initiatives to conversation must first of all be considered
as a sign of trying to make the situation more balanced.
Several actions of both give the impression of offering
participation on a more equal basis, but do so only to a
certain degree. For instance, the therapist, through her
treatment and her explanations, helps or teaches or
encourages the patient to pay close attention to her
shoulder joint, her muscles, and the movements of her arm.
On the other hand, she does not need the patient’s accounts
of her experiences. The patient, who demonstrates a
willingness to cooperate, provides plausible explanations
for lack of progress. However, it is unclear if those same
suggestions are invitations to serious discussions about
and reflections upon the treatment itself. Each "offer" is
ambiguous and raises the question whether authentic
participation is intended or not. And how is this related

to control?

270

A Second Analysis
of the Physical Therapy Literature

Turning to the physical therapy literature, in the
light of the findings from this study it is possible to
analyze why such phenomena as control and participation are
presented in the way they are and to suggest complementary
views. To recapitulate briefly, the way practice is
described, treatment and communication are conceptualized
in the literature as going from the therapist to the
patient. The therapist’s rational and intentional actions
are held up but not the patient’s. The therapist is the one
who provides or facilitates healing for the patient. The
patient is someone who needs help and who either is
motivated to get well and to comply with the treatment
regimen or not. A contrasting relationship is thus set up
between the two. All this indicates a way of looking at
physical therapy as unidirectional and deterministic. It
reinforces the medical definition of the situation.

The descriptions of physical therapy practice that
prevail in the literature, and which might be
representative of those which are used in physical therapy
education as well, identify or equate, in a sense, physical
therapy with what therapists do during "hands-on" phases.
It is during hands-on phases that the therapist is "in
control": it is here that her competence comes into play;

it is here that the purpose of the session is visible in

271
concrete actions. However, in such a model several features
remain implicit and others are excluded: the patient’s
participation in the form of silent, physical responses on
which the therapist grphhde_her_feedheek: the patient’s
talk in the middle of treatment which turns the therapist
into someone who listens: the right time to start a hands-
on phase, which many times means that the therapist is
someone who yeire; the right time to terminate a hands-on
phase, which turns the therapist into someone who hergeihe;
and all that happens during the hands-off phases. Thus what
is focused upon in the literature does justice to only half
of what happens in treatment situations and, consequently,
only half of what the therapist actually does.

The same goes for descriptions of the patient. Her
problems are naturally given the most attention, but her
other attributes are seldom considered. This study shows
that while a patient does bring problems, she can also
provide solutions. By talking about her dilemma, she can
turn the treatment session into something psychologically
beneficial for herself. By formulating her opinions or
attitudes regarding her condition, she also teaches the
therapist about them. By telling about her experience, she
shows that she learns, how she learns, and what she learns.
It might well be that a patient learns things that a
therapist never intended to teach or considered herself to

be teaching.

272

As for the therapist’s work, her instructions and
feedback are treated as natural properties of her
professional responsibilities in the literature. That the
patient, given time and motivation, learns what the
therapist teaches is also taken for granted. What other
things a patient learns as well are seldom discussed.
Evidence of additional learning or unintended consequences
of a therapist’s teaching is reported by Taussig (1980). In
that case, a therapist’s instructions unwittingly made a
patient distrust her own experience so that she became
unable to rely on anybody else’s help but the hospital
staff’s. When the patient was asked (Taussig, 1980) why
nobody but a professional could help her walk, she

responded:

Because she (Becky) would teach you wrong, when a
professional already knows and has evaluated your
muscle strength.... But Becky hasn’t been taught
how to grab me or stabilize me.... or tell me
which muscles to use to keep myself from
collapsing. So, see, she can’t help me
professionally.... That technician still has her
mind working on far beyond mine. Mine is strictly
in trying to accomplish what she has already
learned and knows. (p. 8)

When questioned again why this Becky could not help
her exercise, the answer was that "She doesn’t know the
extent of your energies ... The professional has to figure
this out before she starts the exercises" (Taussig, 1980,

p. 8). Taussig then asked, "You yourself wouldn’t know the

273
capacity of your own energy so you could tell?" The patient
exclaimed, "No! No!" Taussig (1980) interprets this as a
sign of the complete alienation of the patient’s own senses

and states that

The critical issue centers on the evaluation of
incapacity and of feelings, such as pain, and
following that on the treatments necessary. Here
is where the professionals deprive the patients
of their sense of certainty and security
concerning their self-judgement. (p. 9)

He also warns that an aura of benevolence can conceal
issues of control and manipulation in treatment situations.

Although Dr. Strauss, the patient with a frozen
shoulder, continued to rely upon her own perception and her
own experience, the impact of the most mundane work of the
therapist, to give instructions and feedback, must be
reconsidered. Every utterance has both a literal,
referential meaning and an implicit social meaning. In
other words, each simple instruction and evaluation by the
therapist is powerful in several ways. It can make a
patient do something; it can help a patient learn
something; it can stress the particularities of the
relationship between the patient and the therapist.

The following section provides some suggestions for
practitioners and researchers, based on the findings from

this study.

274

Implications for Therapy

This study has attempted to provide an alternative way
of looking at treatment situations. As such, it has aimed
at describing how complex any treatment situation is. The
people that are involved, who come together for a specific
purpose, form a group which develops certain ways of
working together. Both the patient and the therapist in
this study felt responsible for the outcome of the
treatment. Both of them were serious about the purpose of
the treatment, but they perceived and enacted their
responsibilities differently. The session that has been
studied in detail here is an example of what happens when a
patient’s condition has gotten slightly worse. A minor
impairment, that is, a stiffer shoulder, disturbs the
patient. The therapist is thus working with a patient who
is frustrated but still eager to work for improvement.

In order to facilitate working with patients whose
condition lasts for a long time, rherepiere_mighr_rry_re

“1°. !L!l"_5. ' ' 9'. !’ 9'. ,‘l P l’? 9
rhe_hreermehr. If a therapist simply tries to eliminate or
"talk away" a patient’s frustration, the result can be the
reverse. Even if the therapist is eager to start the
specific treatment, room should still be given for the
patient to express whatever she wants to. Otherwise the

same phenomenon can appear in physical therapy situations

275
that Korsch, Gozzi, and Francis (1968) found in their
study, namely, that patients, in this case mothers of
children at an emergency clinic, stopped listening to those
doctors who did not take their concerns seriously. Those
mothers could not recall what instructions they had been
given, and consequently did not comply with the treatment
regimen.

Caution should also be taken not to classify
everything a patient says as a sign of frustration even if
the topic is the injury itself. At the same time a
therapist is thinking about how demanding it is to listen
to a patient’s story, she might remind herself to accept
that and avoid the temptation to change the topic. This
suggestion disagrees with one of Shepard’s (1986), namely,
that a therapist should take advantage of her position and
turn conversations away from the patient’s specific bodily
concerns. This thesis argues that time should be allowed to
examine more closely and reflect upon yhep a patient says

about her physical problem. This might best be done after

the treatment session. In other words, re_phdererepd_rhe
patient—ethnpsmhigulx. that is. to discover the

perspective from which the patient reasons and to take
those findings seriously, might benefit both the patient
and the therapist. It might result in realizing that
treatment plays a role for the patient which may differ

from what the therapist believes. It can also result in

276
realizing that the patient is influenced more by factors
outside of the treatment situation than by the instructions
she is given.

By doing this ethnography, insights can be gained
about how the patient perceives her condition; how she
tries to understand what has happened to her and what is
happening to her, and how she experiences the ongoing
session itself. The impact of the treatment situation upon
the patient might also be rediscovered.

A therapist should aware of how quickly one’s role can
change. Comments during daily practice which are merely
meant to be feedback upon the patient’s performance might
in fact change the working relationship. A word of praise
might remind the patient about the different status between
herself and the therapist. With only a brief phrase, the
therapist steps out of the working relationship and becomes
or takes the position of someone who judges somebody else’s
performance. Saying, "Your shoulder is functional. You can
use it the way it is" to a patient who already knows this
is like saying, "It is my professional responsibility to
evaluate your condition properly and to let you know what I
have found out." But behind this lies a misconception or
bad habit. It might not be necessary for a patient to be
told or informed about something she has concretely
experienced herself. It might in fact indicate the the

therapist has not paid attention to what the patient has

277
said and demonstrated during the ongoing session. It might
indicate that the therapist has refrained from learning
from the patient.

The professional’s primary responsibility for each
session should be to find the answer to the question, "What
sense does the patient make of her condition redey?" To
assume that a patient’s impressions or attitudes are static
over time is to underestimate the impact that any event, or
life itself, has upon a patient. The changeability of a
patient’s attitudes must be recognized and accepted. The
same flexibility should be held toward the patient’s
perception of the outcome of the treatment. Even if
improvement is measurable in degrees, the patient might not
be pleased at all. Or the situation can be the reverse. In
other words, it might be naive to assume that a good
treatment outcome, from the therapist’s point of view,
makes the patient equally pleased.

No matter what, therapists must not expect that
patients’ attitudes are stated directly. Rather, they
appear in different forms, in different words, at different
times during each session. Therapists should neither expect
that patients will fully embrace the professional’s
assessment of the condition, nor try to impose the medical
definition of the condition upon the patient. Such
impositions can lead to a patient losing one of her "trump

. cards," namely, I'the practical knowledge she has acquired

278
about her illness and the medical institution" (Lacoste,
1981, p. 179).

Another way for the therapist to avoid confrontation
with the patient in the treatment situation is to accept or
acknowledge whatever opinion or comment the patient makes
hetere stating her own, whether this confirms or
disconfirms the patient’s. And, attempts should be made to
figure out how oneself and the patient one is working with
do reach consensus. An alternative approach is to
conceptualize treatments as negotiated achievements, as
described by Green Schwartz and Kahne (1983). By reflecting
upon issues like these and getting accustomed to this way

of analysis, a therapist could learn to think about the
theraeeutic_2rgcess and not only the therapeutic_eutceme.

Implications for Research

The theoretical and methodological issues this study
raises with respect to face to face interactions concern
first of all the treatment dialogue itself, but also its
inter-weaving with the brief conversations. The
relationship between the vocal instructions and the non-
linguistic responses that has been found in this study
argues that kinesics might be expanded to see movements as
not solely in connection with one’s own talk but in

connection with somebody else’s. To learn also to see

279
movements as propositions or statements equally powerful as
vocal ones might lead to the recognition of their
meaningfulness.

The continuous weaving of the treatment dialogue with
the brief conversations, with the therapist being
responsible for the vocal part of the treatment dialogue
and the patient initiating most of the conversations, shows
that there are rapid shifts in participation structure
throughout a session. This challenges the notion of
professional authority being firmly part of the
occupational role. Only at certain points in time is this
the case.

Problems in medical encounters, which are frequently
addressed in the literature, can be related to these rapid
shifts, but they can also be caused by the different styles
the professional and the patient use while talking. While
the professional dominantly uses particular registers, the
patient dominantly speaks in the most ordinary way,
identified in this study as "making conversation." Further
studies are needed in this field.

Another area of research that this study bears on is
the field of pedagogy, of teaching and learning. Studies of
practice can contribute new insights into the role of
knowledge, including cognitive as well as bodily knowledge,
in treatment situations. By assuming that the patient and

the therapist possess and express both cognitive and bodily

280
knowledge in the course of treatments, one can study hey
this is done. Such studies encourage new analytic
perspectives on teaching and learning that are pertinent to
the field of physical therapy.

Based on Erickson’s discussions about staff
development in teaching (1986c), the following axioms and
questions could serve therapists and researchers alike as
grounds for rethinking the nature of physical therapy.

1. Every patient and every therapist is working on
something or doing something all the time. The question a
therapist or researcher can ask is "What is the patient/the
therapist occupied with right now?"

2. Everyone is someplace. That is, nobody is ever no
place. The question can be "Where is the patient/the
therapist right now and what is she working on?"

3. Everyone is continually making sense. "It is not
that some people make more sense than others or that the
teacher is making sense and the children are learning how
to make sense, everybody is making sense all the time"
(Erickson, 1986c, p. 16). One can therefore ask "What sense
is the patient/the therapist making of what is going on
right now?"

4. Everyone teaches and learns. But who is teaching
what? Who is teaching whom? Where and when does this
teaching take place? Therapists should ask, "What does this

patient know? What is this patient trying to teach me? Why

281
is the patient trying to teach me this right now? How does
this patient learn?"

5. Not everything that happens in a treatment
situation is accessible or visible to both the patient and
the therapist. One cannot attend consciously to everything
that happens, as many things go on at the same time. The
question becomes "What is visible and what is not for the
patient/the therapist in this session?"

6. Any treatment situation is influenced by things or
actions that have taken place prior to the ongoing
treatment. It is also influenced by the anticipation of
future actions. The question can be formulated as "What
past and future actions play a role in this treatment

situation?"

Implications for Education

The findings from this study are suggestive of
implications for professional development and physical
therapy programs, as the study has questioned the
relationship between a patient and a therapist: as it has
questioned what is therapeutic about treatment: and as it
has questioned ways of gaining knowledge.

One way to provide an opportunity for experienced
physical therapists and teachers of physical therapy
programs, and thus indirectly physical therapy students, to

282
reframe their thinking on these matters is to present
videorecordings of treatment situations. This can be done
in a fashion similar to what was briefly described in
chapter three under the heading "Issues of
Trustworthiness." One prerequisite is that the videotape to
be shown is thoroughly analyzed beforehand. The advantage
of making frequent revisits to the same scene permits
uncovering of how treatment situations unfold in real time.
It allows for paying attention to one feature on the
videotape at a time or to the combination of several ones.
It challenges inferences made too fast. Discussions can be
organized around the following exercises:

1. Comparisons between individually held assumptions
about the profession and the visible carrying out of
practice can be made.

2. Knowledge acquired from textbooks about a certain
condition can be compared and contrasted to knowledge
derived from working with patients having that condition.

3. Attention can selectively be paid to how patients
express their knowledge, how they verbalize their
experience, how they understand the same experience, how
time alters their understanding, what logic or lack of
logic they see in the origin and development of their

condition, and how they come to cope.

283

4. Listening for clues to intervention that many
patients directly and indirectly give during treatment can
be practiced.

5. Theories of communication, vocal and non-vocal, can
be contrasted to the practice of communication, with all
its complexities and the complications that inevitably are
part of any interaction.

6. Attention can be paid to moments when "things go
wrong," in order to establish what is happening when
"things go right." This is not meant to search for
difficulties, but the smoothness of actions when "things go
right" needs to be contrasted to more unsynchronized
actions in order to be "seen."

7. Discovery the local moment to moment co-production
of any treatment situation in focusing upon the
contextualization cueing of the participants.

8. Awareness of the inseparateness of language and
movements, one’s own and others, and the implications they
carry, alone and together.

9. Questioning the concept of motivation.

Another way to learn about those same issues or
concepts, for physical therapy students and experienced
therapists alike, is to have one or more videotapes made of
oneself when working with patients. These videotapes should
then be discussed with a social scientist or a behavior

scientist. To study one’s own behavior in treatment

284
situations will facilitate uncovering, for instance, what a
patient says and does; what one hears the patient say; and
what movements or words by a patient one responds to or
ignores. It will help in rethinking what physical therapy
treatments do to patients. It will help in rethinking the
purpose of physical therapy.

Finally, in order to understand clinical practice and
subsequently improve treatment situations, more
naturalistic studies of therapeutic encounters and
relationships need to be carried out. By using concepts of
teaching, learning, and communication, fruitful insights
can be gained about the social complexities of treatment

situations.

285

EPILOGUE

Six years after this study on July 15, 1990 the
patient, the physical therapist and I met again. It was the
first time we had met outside of a treatment situation,
this time over dinner. The therapist had invited the two of
us and the first topic that came up was, naturally, that of
the patient’s shoulder. How was it doing? It proved that
the patient had had no more problems, that she still had
full mobility of her shoulder. She demonstrated full
forward flexion and full external rotation, but was unsure
at first of how to position her arm.

When the therapist jokingly said "You must have used
the pulley," the patient shook her head. Instead, she had
regularly been going to exercise classes ever since 1984,
because she was going to make sure that "This was never
going to happen again." "This" referred both to the
condition itself and to the treatments.

The patient recalled the awful pain her shoulder had
caused her and that ne_ehe could understand what it was
like. This was said while glancing at the therapist, as if
to say "You were the only one."

The patient described vividly the treatment sessions,
remembering many details. She brought up some of the things

the therapist had said, which the therapist denied,

286
claiming, with a smile "I wouldn’t say anything like that."

The therapist talked about the treatment sessions in a
different way. She commented upon my presence during the
treatments and stated that it had been good to have me
around, good to "break the monotony."

When talking about this dissertation, both were
interested in reading it. The patient because there were
lots of things she did not remember or had chosen not to
remember, "It was such an awful experience to have a frozen
shoulder": the therapist because she wanted to find out
"what she was doing in her work."

Thus, six years later the patient and the therapist
interacted much in the same way they had done before. Their
recollections of the treatment sessions confirmed how
differently they had experienced the same situations. And
still, there were some things the patient had not learned.
The pulley, important to the therapist, was not so to the
patient; active exercises were.

The reliance upon the therapist as someone who would
not only help the patient regain mobility but also as
someone who would understand, strengthens the argument that

treatment sessions serve multiple functions.

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APPENDICES

296

APPENDIX A

DATE AND NUMBER OF "STEPS ON LADDER"

 

TIME

l/18/84
1/20/84
1/23/84
1/25/84
2/15/84
2/27/84
2/29/84
3/29/84
4/12/84
5/01/84

5/31/84

NUMBER

RIGHT ARM LEFT ARM

20

22

21

23

25

25

27

28

28

30

29

28

31

30

All numbers are recorded in fieldnotes of the same date.

297

APPENDIX B

E] . 1 II . I : ! E

Ms. Kerstin Ek, a doctoral student at the College of

Education, Michigan State University, is conducting a study

to explore what communication skills are required in the

delivery of physical therapy. "Improved communication,

improved care" is the topic for her dissertation.

Ek would like to ask your general consent to be a

participant in the project. This consent includes your

permission for her to observe your interaction with others.

1.

You are under no obligation to participate in
this project, and you may withdraw your consent
at any time.

The notes from Ek’s observations of your
interaction will be kept locked in her file.

No one will be allowed to see these notes
without your written permission except for

Ek and Dr. Frederick Erickson, a member of

her doctoral committee. Since Ek will use

some ofthe information contained in the

notes as part of her dissertation and
consequent teaching endeavours, she will
disguise the names of all the persons and

places (yours included) to prevent anyone from
identifying you.

The observations Ek will make and discuss with
you are for research and educational purposes
only.Neither you nor any other person - including
your supervisors, patients, or Ek - will use the
observations in evaluating any health
professional’s behavior, or in pursuing any legal
or administrative action. ‘

Ek will be pleased to talk to you further about
these and other aspects of the project at any
time. She can be reached at (517) 355-6006 or
(517) 353-6413.

298
I have read and understand this form. I have had a
chance to discuss the project with Ek. This consent form
includes having Ek observe my interaction with others. I
agree that data from these observations will be used

accordingly to the conditions stated above.

Name 3

 

Hospital:

 

Witness:

 

Date:

 

299

APPENDIX C

O O 0 O 0
'9 a z 9' a9 : “11‘! ogn e V 9‘0 2!. 1-0 e :9 0

Ms. Kerstin Ek, a doctoral student at the College of
Education, Michigan State University, is conducting a study
to explore what communication skills are required in the
delivery of physical therapy. "Improved communication,
improved care" is the topic for her dissertation.

Ek would like to ask your permission to make a video

or audio tape of your behavior for her project.

1. You are under no obligation to make the video or
audio tape. At any time you can withdraw from the
video or audio taping process or have the video
or audio tape erased.

2. Ek will review the tape with you as part of her
project. She may use portions of the video or
audio tape or transcribed sections as part of a
training course in communications skills for
physical therapists.

3. The video and audio tape will be labelled with an
anonymous code (not with your name) and it will
be kept locked in Ek’s file. The video and audio
tapes are intended to be used for research and
teaching purposes only.

4. Ek will be pleased to talk to you further about
these and other aspects of the project at any
time. She can be reached at (517) 355-6006 or
(517) 353-6413.

I have read the patient’s consent form and agree to
participate in the project, recognizing the possible risk
that the video and audio tape might be subpoenaed in a

legal dispute. I have read this form and I consent to have

300
a tape recording made of my behavior on (day)
at (place and situation). I agree that
the use of this tape will be goverened by the conditions
stated above.

Signature of the physical therapist:

 

Hospital:

 

Witness; Date:

 

301

APPENDIX D

’-. ‘9 091s? ,9911 0, 9° ‘11-. e! :11 e 9‘0 0 ;_°._o

Taping

Ms. Kerstin Ek, a doctoral student at the College of
Education, Michigan State University, is conducting a study
to explore what communication skills are required in the
delivery of physical therapy. "Improved communication,
improved care" is the topic for her dissertation.

Ek would like to ask your consent to observe and/or
video or audio tape your interaction for her project.

Here is some information about the video or the audio

tapes, the observations and their use.

1. You are under no obligation to agree to make the
video or audio tape or allow the observations.
At any time during or after the video or audio
taping,you can withdraw consent and have the
video or audio taping stopped, or have the video
or audio tape erased, once it has been made.

2. The notes from the observations will be kept
locked in Ek’s file. No one will be permitted to
see the notes except Ek and Dr. Frederick
Erickson, a member of her doctoral committee.
Since she will use some of the information
contained in her notes as part of her
dissertation and as part of a training course in
communication skills for physical therapists, she
will disguise all names (including yours) to
prevent anyone from identifying you.

3. The video and audio tapes will be kept locked in
Ek’s file, labelled with a code number (not your
name). Ek will review the video tape with the
physical therapist to help her improve her

302

communication with patients. Part of the video
and audio tape or transcribed sections of

them may be used in Ek’s dissertation and the
training course she intends to develop and your
name, and if you so wish, your image will be
changed so no one will recognize you.

4. The observational notes and/or the video and
audio tapes are intended to be used for research
and teaching purposes only.

5. Ek will be pleased to talk to you further about
these and other aspects of the project at any
time.

She can be reached at (517) 355-6006 or (517) 353
-6413.

I have read this form and I consent to the following.

(Please select one and cross out the others).

a. to have a video tape made of my behavior
b. to have an audio tape made
c. to have observations made of my behavior

d. to have a video or audio tape and observation
made

of my behavior.

I agree to the use of the tape or observations under
the
conditions stated above.

Signature of the patient:

 

Place:

 

Witness: Date:

 

 

Amount of stretchings
per hands on phase

 

//

/

 

303
APPENDI

 

 

 

 

X E

 

 

 

 

 

 

 

 

 

// / / /
FF ER ER IR IR
Video I, 1/18/84 Time

 

//

 

 

 

 

//

 

 

//

 

 

 

 

 

 

//

 

 

 

 

FF ABD ABD ABD ER
Video v, 2/1/84 J
k 7" .1. _ '—
// / // // // W, //
FF FF ER ER ER FF FF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Video x, 5/3/84

Amount of phases and stretchings per hands-on phase on three
different occasions. Filled bars = Hands-on phases; Space in
between = Hands-off phases; FF=Forward Flexion; ER=External

Rotation; IR=Internal Rotation; ABD=Abduction

304

APPENDIX F

TRANSCRIPT: HANDS-ON VI (FORWARD FLEXION)

 

 

259/94.4205!!!
T: Yeah That’s reall looks betterlthan when welstarted out
#andx-an NP: Yeah

Let me get it out to the sidevgs that painffiI.At that
plaEE You do better at this one

P: Yeah ((P exhales))
T: Okay
O 0 ~
P: It hurts right 1n here

T: Okay Okay Go push (6 s) Give it a
real hard push ... .. Good and relax

P: Ah ...

T: Reach
wa::y out ..

P: Ah

T: Push again (6 s) And relax .... And reach
You’re reaching

P: Maybe
_/’
T: Hm
P: Maybe the
difference is that it is just hard for me to tolerate two
days in a row
/”\
T: Uhum
((P exhales))

T: Okay .... Go down

\ \
T: Real tender You have Yeah it’s hard then

305

P:
‘\
let go v
P: Aha
\
T: To let me stretch ..

P: Yeah it was real
class when I was lecturing I had I kept I had to
rubbing my shoulder

Wait-v02? T: HmJ
flodr —W/fl-

Aha
T: To

sore in
keep

306
APPENDIX G
TRANSCRIPT: E 6:1

31:59
P exhales ....
(Pain in
face)
..//
T: we cantgggp and then we can go a little
further You wanna do
:04
P: I don’t c528 Ah I think I just
(Whispers) (Pain in face)
wanna stop

T: Oka I’ll hold it right the;e

22:09

P:Ahoooo
(Pain in face)

(T gives an
32:13
extra push before bringing the arm down)

32:14
—\~ T: Move it bac
That’s good ...
(P’s face in pain)
(T starts rubbing P’s upper arm and back of shoulder. As T
brings the arm down she slumps slightly)

32:20
P: Ah A::h I can[. 1
(T removes he right h nd, goes on rubbing P’s upper
arm, rolls towar s P’s he d, slumps more)

.2’
T: Not hurt ng that bad Yeah Not hurting that
bad right there
(T’s voice drowns P’s words. T’s hand on
back of P’s shoulder)

P: No it’s not in the bask.It hurts more up
(Normal tone of voice. P touches upper arm)

307

\
here
32:32 .\
T: That one loosened up quite good ... Not too 5:8

32:37
(T removes

her left hand)
P exhales

32:41
(P stretches right arm toward

ceiling)

32:42
(T stretches her back)

32:43 _/
P: Good stretch hm

(Happy voice)
84.5

T: Uhum Tough on
(10 s)

(T scratches left wrist. P stretches arm toward ceiling,
bends at elbow, stretches up again, keeps arm straight,
moves it slightly backwards)

32:51
(P sighs, then puts down upper arm
on table, 90 degrees at elbow. P "slaps" elbow on table
once more, T smiles. P sighs)

32:55
(P turns face toward T. T nods)

32:56
T: Ye?p That “\y Over the he}:
(T points three times toward the wall behind P’s head)

32:59
(P puts arm in position for ER)

33:00
'1'er
(P rolls back on left side,
puts both hands on stomach, closes her eyes, while T shows
FF. T then slaps right hand on table)

P: BIzh

308

(P sighs,
adjusts head on pillow, moves it closer to T)

33:03
(P slaps both arms on
table, sighs)

33:04 \
T: You de good with rest in between

309
APPENDIX H

TRANSCRIPT: TRANSITION HANDS-ON V/HANDS-OFF VI

P exhales ....

T: We can 5568 and then we can go a little
further You wanna do th

P: I don’t caEE Ah‘I think I just
wanna stab

T: okEy 1'11 hold it right théPe
mi}:

R\ T: Move it
back That’s 9838 ... 1

Ah A::h I can[—

"U

.z’
«e T:lNot hurtiJg that bad
Yeah Not hurting that bad right there‘

_\ P: No it’s not in the
back It hurts more up he;e

fiéxmd9-nnzl?.\’ T: That one loosened up quite 9533
... Not too bad_]

%”/J.#Z. ((P exhales))
P: Good stretch Inf

v \
T: Uhum Tough one
(10 s)

.\
T: Yeap That 62) Over the hezd Nb
BI;h ((exhales))

1‘?

.\ T: You de
good with rest in between

310

APPENDIX I

DATE AND MEASUREMENT OF SHOULDER MOBILITY IN

 

DEGREES
TIME FF ABD ER IR
10/07/83 150 85-90 50 WNL
10/25/83 164 125 63 WNL
01/09/84 90 75 x x
01/25/84 95 85 5 20
01/27/84 -- . 70 -- --
01/30/84 100 90 -- --
02/01/84 100 90 (p) -- --
02/06/84 105 95 10 30
03/16/84 140 (p) 130 (p) 35 55
03/29/84 160 (p) -- 50 (p) --
145 (A) 45 (A)
04/12/84 160 (p) -— -- --
145 (A)
05/22/84 160 -- 30' --

FF: Forward Flexion
ABD: Abduction
ER: External Rotation
IR: Internal Rotation
WNL: Within normal limits
: Not checked, too much guarding

311

P: Passively
A: Actively

These measurements are recorded in the therapist’s progress
notes. Those from 1983 are carried over from the patient’s
previous treatments at another physical therapy department.

n ‘. '.\.:.