The Search For Answers

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You know there is more to know. The information age allowed you to find out more and now you feel like there must be something more. You just need to find it.

What do they know that I don’t know? You see all these polished profiles in cyber space touting people with all the answers. How-come you don’t know all the answers. They have complex theories based on large combination-of-terms frameworks (neuro-modulatory-spinal-control-protocol, Boss-mom-investor-athlete-morning-routine, etc). Is that the thing you’re missing? Continue reading

The Best KPI in Physical Therapy

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Is profit the best KPI in health care? Is volume of patients in your clinic a good measure of your business’ mission? Is there a better “healthcare” KPI?

A KPI is a Key Performance Indicator and the purpose for these in your clinic are multiple. They are objectives that produce data points that are used to track objective items. They are meant to be representative of the work you are doing, so that an outside source (typically your manager or owner) can know what you are doing day-to-day. In application: They are meant to signal to you, the clinician, what is important to your manager. It also signals to the manager what is important to the company, or the share holders, or the owner.

KPIs had their modern start in the 1920s with the DuPont Table, and in the 1930s with the Tableau de Bord or Balanced Scorecard. Since then companies far and wide, from Google with their “OKRs” to your private practice PT company, use them to track data, align values and drive behavior.

KPIs are data. These pieces of data (often in dollars, or visits per month, or number of referrals, or units per visit, or whatever your company deems important) are used as a communication tool. “The signaling of importance.” Aka: how you are going to be judged as successful… because this is how they are judging themselves as successful.

If a KPI signals “Importance” then isn’t that what you’re supposed to be focused on? Continue reading

Quad Responsiveness. Clinic Hack.

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Getting the quadriceps functioning again after surgery is a serious task. Effusion and pain inhibition “shut down” the quad and atrophy can set in very quickly.

You will be loading the quad, both in open and closed chain and I must recommend that you spend time under tension to stress the muscle tissue and develop strength. Progressive overload, with respect to tissue healing timelines, is paramount.

Once a base level of strength is developed, and the patient can clearly generate force, the next thing to progress is speed, or quad responsiveness. I hesitate to call it “Rate of Force Development” because I’m not taking any force curve data with this method, but it does work speed and reaction time and the nice triphasic neuromotor pattern needed to start and stop a motion. Continue reading

A pitfall of patient-centered communication

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I’ve come back from physician visits without a clear idea of what my physician thinks. I think I’ve found a problem, and I believe it’s communication. 

The push to be patient-centered and take all patient preferences in to account has morphed in to a wishy-washy communication style which boils down to the clinician saying “Well, whatever works for you. What do you want to do?” This, in turn leads to conversations at home with spouses and friends of “I don’t know, I wanted my doctor’s professional opinion and they told me I could do what I want. They gave me options but not direction”

Continue reading

The Three Question Test for Exercise Implementation

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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

Explaining Context

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…

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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

This is the person you are trying to help

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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

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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

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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