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.

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:

This is the person you are trying to help

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.

N=1

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.

Patient Education Binder

Visual aid with pt Ed. My imaging and pain concept binder v1.0 HT @AdamMeakins @paincloud1 … pic.twitter.com/RKippepias

— Matt Dancigers, DPT (@MattDancigers) April 29, 2016

Seeing is believing. It can be also expressed as “only physical or concrete evidence is convincing” which you surely have heard as a popular argument on many fronts.

Well, your patients are human, and thus, adding physical evidence to your statements or positions can aid in understanding and spur conversation.

Dr. Spencer Muro ( @SpencerMuro ) suggested that, when educating pt’s on pain science or imaging results, we use the above concept to corroborate our “claims.” Use visible evidence, not just repeat it verbally. Enter: The Patient Education Binder.

We used to show patient’s pictures of these images on our phones, but a print-our hard copy in large font is more useful and meaningful (personal anecdote). So we did not make these images, and I will give credit to the maker’s / authors of them. I asked The Sports Physio ( @AdamMeakins ) to tweet some of them, PainCloud.com ( @PainCloud1 ) produces great stuff, the rest are found on Twitter or a search engine. Disclaimer disclaimer etc.  (Most credit is available on the image itself). They are great representations of current understanding.

If they help us understand, why not share with your patient?

G O A L !

What you perceive today as a struggle is not truly due to the task at hand. It has to do with what the goals of the activity are.

The goal determines how the steps will play out. A worthy goal can bring you through any tough time. If the outcome is not of interest to you, no simple/light task is easy. It’s all a struggle if the goal is not meaningful.

The advice we give

image credit

Do this drill: Ask yourself “Do you think that everything you believe or think about the world is the truth?”  (Most thinking people will say ‘no.’) Follow-up with this question: “What are you wrong about?” … hmm…

We often think our way of thinking and understanding the world is correct. Well, we always think we are correct and act on it, but we know deep down that, since we are human, we cannot always be right. This is besides the point a bit, but this post deals with our advice, our own beliefs in what we and others should do. Sometimes there is a disconnect.

Experience and the Experiment

Image Credit

“Dad, let’s do an experience” my 6.5 year old said to me this morning. “Let’s see how far away these walkie-talkies can go and we can still hear each other.”

“Do you mean experiment?” I ask. “Yes, ex-per-i-ment” she says. We go over its pronunciation a few times. It’s a mix between my daughter having no front teeth and that she just gets her word choices mixed up now and then. Experience. Experiment. It’s an easy one to slip up on, plus they could be viewed in the same category in her head. “I will have an experience and learn something.” “I will do an experiment and learn something.” Same thing, basically, to a 1st grader.

So, you can see this question coming: Do you get Experience and Experiment mixed up?

Cervical Artery Dissection: Implications for the Physical Therapist A Case Report from a Direct Access Environment

http://2.bp.blogspot.com/-mayPxpjVzes/U-y_PpjFEzI/AAAAAAAABA0/9NntkiP_fsk/s1600/A9RBABA.jpg

Intro:

You receive a call from your friend and fellow DPT classmate to evaluate her neck… the patient herself is a physical therapist by occupation. A healthy and fit 29 year old female, 5’0″, 115lbs. She reports she is having some cervical musculoskeletal issues going on. She has an achy pain in the bilateral upper traps., levator scapula, and peri-cervical muscles. She is limited by pain with the following cervical motions: right side-bend, right rotation and extension. No signs of central or peripheral neurological issues.

You are an experienced PT and have completed many cervical manipulations on a patient like this and it’s the end of your day. So you are going to do a quick favor for a friend and manipulate her neck, complete some STM, and maybe some PROM/SNAGs/isometrics/METs or whatever your favorite manual therapy technique is. What could go wrong? She’s a therapist herself so she wouldn’t miss anything serious. Being that you are friends you want to do some “magic” giving her some relief of symptoms. So… snap, crackle, manip. You move into some PROM and she reports severe vertigo, nausea, double vision, and you notice hemi-facial asymmetries as she talks about her onset of symptoms. Now what?  Your table, your hands, your patient.

The Crossroads of Philosophy and Physiology (Part 2): Where We Missed the Mark on Pain Education.

 

And you’d be surprised… the answer goes further back than you might think.

So if you read Part 1, we left with a series of questions — all boiling around the conundrum of what I will call “the pain education lag.” This can be defined as the time it takes for the education to take an effect (i.e. reduction of aberrant pain). Essentially, you provide a treatment, but it’s possible for no effect to be seen immediately (and its also highly likely for this to occur in such a delayed fashion). And this is something that is significant. Other treatment effects take place immediately. Yet, with pain education