The role of the primary treating physical therapist, especially for the young child between the ages of 1 and 5 years, will incorporate the typical role that the grandmother and the general pediatrician play for normal children. In addition, the therapist fulfilling this role must have knowledge and experience in dealing with children with CP. This role model involves time spent teaching the parents how to handle and do exercises with their child. This role also involves helping the parents sort out different physician recommendations, encouraging the parents, and showing and reminding parents of the positive signs of progress in the child’s development. When this role works well, it is the best therapeutic relationship a family has. The positive aspects of this role are providing the parents with insight and expectations of their child, reassuring the family that they are providing excellent care, and being readily available to answer the family’s questions.
The “grand mothering” role of the therapist has associated risks. One of the greatest risks in our current, very unstable medical environment is that a change in funding or insurance coverage may abruptly end the relationship. An abrupt change can be very traumatic to a family. The therapist must be careful not to be overly demanding of the family, but to help the family find what works for them. Occasionally, a therapist may be fixated on a specific treatment program and believe that it is best for the child; however, the parents may not be in a situation to follow through with all this treatment.
The parents feel guilty, and the therapist may try to use this guilt to get them
to do more. The physical therapist in this role as a therapeutic “grandmother” can help parents sort out what medical care and choices are available. The therapist can help parents by attending physician appointments and making the parent ask the right questions, which is often not possible because of funding restrictions. The physical therapist must not give specific medical advice beyond helping parents get the correct information. Therapists with extensive experience should recognize that they have great, detailed, and deep experience with a few children and that generalizing from the experience of one child is dangerous. We have heard therapists tell parents on many occasions that their child should never have a certain operation because the therapist once saw a child who did poorly with that surgery. This type of advice is inappropriate because one child’s experience may have been a rare complication of the operation. Also, there are many different ways of doing surgery. This would be like telling someone to never get in a car again after seeing a car accident. A more appropriate response to the family would be giving them questions to ask the doctor specifically about the circumstance with which the therapist is concerned and has experience.
Another physical therapist therapeutic relationship pattern is the purely clinical relationship in which the therapist thinks the family is incompetent, unreliable, or irresponsible and only wants to deal with the child. Almost invariably, this same therapist next will complain that the family and child never do the home exercise program or that the child is not brought to therapy regularly. This relationship may work for a school-based therapist or a therapist doing inpatient therapy, but it leads to great frustration for both the therapist and family when it is applied to an outpatient-based, ongoing developmental therapy. In this environment, the therapist must try to understand and work within the family’s available resources.