The Search For Answers

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?

The Best KPI in Physical Therapy

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?

Quad Responsiveness. Clinic Hack.

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.

A pitfall of patient-centered communication

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”

The Three Question Test for Exercise Implementation

3 question test

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:

Recent Videos on Pain and the Brain

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.

It’s Time for Change – Lessons from the Origins of Pathoanatomy

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?

To understand our present situation, I think

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…

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.

Restricted Thoughts

 

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

Two Tales of Cognitive Diagnostic Error

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…