One of the first tasks given to students on clinical rotation is to come up with an exercise flowsheet, or plan, for a patient they have just evaluated. This seems pretty standard in the outpatient orthopedic setting for students.
This task is often hard enough for many students. They work through it and I question their decisions and ask why they picked a certain movement. It’s harder than it sounds to predict how things will go and what they should work on. I always let them work on this independently at first, then we discuss their thought processes.
I’ve started using a Three Question Test for each item on the flowsheet. I’m not sure this originated with me, as I have been mentored by many and have picked up ideas from lots of smart folks. But here is the current question sequence: Continue reading →
I’ve have a handful of “Go-To” videos I share with people when I want to get them up to speed on pain science topics. Recently there have been a few more videos surfacing, and I wanted to place them here in a post for you, in-case you want some updated material, or new concepts.
Recently, there has been no shortage in the peddling of structuralist misconceptions. Patients continue to fall prey to misguided efforts by healthcare workers to address their aches and pains. You see bizarre tendon lengthening surgeries, talk of ring shifts and sacral torsions. Worse than all of this, clinicians continue to fall prey to these delusions as well. They take courses taught by gurus with widespread acclaim, but little support for their actual claims. This is where we find ourselves in modern medicine–in the midst of an ever growing debate, discussion, argument (or worse) surrounding the the plausibility or lack thereof for such theories.
We tend to argue our points from research and “evidence.” Which tends to be met with other “research and evidence.” Some take more aggressive maneuvers to call out non-sense, but ultimately clinicians continue to choose to follow these misguided beliefs and practices. And it begs the modern philosophical question, Y tho? And what can we do to move our profession forward?
When people ask “why does it hurt?” I’ll get around to stating that “… also, context of [your pain] is a factor in how it feels.”
Now this may make sense to you, the PTBT audience, but this is often not an idea that people have thought of. Most people only remember a politician saying his/her words were “taken out of context” so it may be important to explain context.
Here are two quick context stories I tell. Please use them, please make them your own…
1.) Context example… “So now let’s say you are walking in a spooky forest, it’s dark out, you’re by yourself, a bit creeped out and you feel this on your shoulder (lightly tickle the skin), what would your reaction be?” Often a patient will exaggerate looking back quickly or state “I would jump, think it was a spider or something”, etc. Continue reading →
Say a child doesn’t have the legal right to drive (we’re talking about an 8 year old). Ask the kid what they want to do, most of the time that task or activity will be restricted to their home. Some people may argue differently,and say, “that’s not true, my kid always wants to go the park.” (or fill in the blank with something else). Maybe that’s true. Maybe that child’s thought process involves things that are outside of his or her control, but maybe that child has an active and willing participant (i.e. the parent) who has made this thinking possible. The parent is actually asking the child what they want to do, taking into consideration the child’s opinion/desires for the best possible outcome for everyone.
What happens, however, when we turn this scenario? What if this is the parent who does not cooperate with the child’s desires? What if the parent is actually a really bad individual, who doesn’t really value what the child thinks? What if the parent has had a long day of driving and doesn’t feel like going back into the car? What if the parent doesn’t have a vehicle? And the biggest question of all, what if the parent does this consistently? Day after day, week after week, year after year? The child’s desires and thought processes are likely to change. They are likely to become narrowed. Instead of going to the movies, or going to get ice cream, or for a day at the park; the child will start only thinking of things to do at home. Like play outside, watch a movie, or read a book (…maybe that’s a stretch).
You can see this happening in real life. I wouldn’t be surprised if there was some bit of academic research on the topic. How children’s minds are shaped, and likewise their thought patterns, by the constraints or liberties placed on their actions. Some people may say, well that’s not a huge issue, especially if the child has a good home. They can stay and play at home all they want! Which might actually be true, but what happens if this scenario is turned into the healthcare field? Lets swap the child for a physical therapist/physio and the parent for the Continue reading →
Health care is busy! We have patients on patients on patients. They come one right after the other, and we have little time between to catch up on documentation. As a matter of fact, most clinics/companies prefer you document while you’re with the patient. All of this leaves little time to reflect on your decision-making with each patient, and this might be a bigger problem than you realize.
Here are two case reports that illustrate examples of cognitive diagnostic error perfectly, both experienced just last week* by yours truly. One, I caught and helped; the other… Continue reading →
In walks your 2pm evaluation. Well, not really…they scoot in backwards, sitting on their four-wheeled walker complaining about how long the medical history form is and “why do you need to know all that stuff?” A long past medical history is fine, you can handle that, you can synthesize how 10 years of uncontrolled diabetes mixes with COPD, a back problem they’ve had “since they were 19” and the multiple progressive knee scopes and procedures they’ve had.
During the interaction, however, the person is “off.” They don’t interact with the ease and simplicity that you do with your staff, your friends or the prior patient. You can’t quite describe it well. Continue reading →
If a tree falls in the forest, and no one is around to hear it, does it make a sound?
Ah yes, a classic riddle indeed and one I will answer. No. It does not make a sound. Let’s explore this, and how it relates to understanding pain and sensation.
First we will define a sound. The English Oxford dictionary defines it as “Vibrations that travel through the air or another medium and can be heard when they reach a person’s or animal’s ear.” You need both waves and an ear to complete the “hear.” So in our above riddle, there is no hear of the sound due to there being no person’s ear in the riddle, as it is in the definition. Continue reading →
N=1 has turned into a symbol, a representation meaning to treat a person as an individual, as a unique complex being that has personal factors and history that make them who they are. (see the mountain stream analogy via Aaron Swanson.) When we speak about treating the person in front of us we can say “N=1.”
This is being championed by many groups. The “Pain Science crowd” certainly incorporates individualism and biopsychosocial constructs. Cause Health is bringing awareness, and I’ll also recommend Neil Maltby’s blog: Becoming More Human. Continue reading →
There’s gotta be a reason. You can’t have an event pass by you without knowing why, right? Right.
“Well, you know, the weather made it hurt. It’s all that rain…”
“My back is hurting today, I was at a family BBQ and I stood for an hour yesterday, so…”
“The knee feels much better, I think it was the tape you put on there.”
Post Hoc Ergo Proctor Hoc. After that, therefor because of that.
Making a reason for things is not conscious, often. We always see cause and effect as a truth. If we’re wrong, it’s confabulation, not a lie. It’s “only human.” See a quote below from some of the Split Brain research: Continue reading →