Starting off a new year

Well it has been awhile since I have been posting.  Over the last 6 months I have been working on completing my post-professional Doctorate in Physical Therapy through Des Moines University.  In December I finally completed all the course work and my final capstone project.  Around 800 hours of study and work over the last 3 years with this endevor, but it has been well worth it.  Since I have been spending most of my nights working on completing this I haven't had much extra time to post.  I'm hoping to find some time in the coming year to getting back to writing and posting on various topics.

I thought I would include an article I recently did for the local newspaper:

Are all exercises created equal? With the plethora of exercises, products, and health fads in the news and hitting the market these days, it is confusing to know what the “best” exercises or products are for you. Many products or types of exercise will make claims of “scientifically proven” or “research shows” on why their type of exercise is better than another to lose weight, tone-up, live healthier and get the body you have always wanted.  Unfortunately, these exaggerations or misinterpretations of scientific literature (which I like to refer to as exercise babble) are all too common in popular culture. Exercise babble aside, most research currently shows the type of exercise you do is of little importance, however it is very well proven exercising in general will make you healthier!

So after sorting through all the misinformation, here is a simple guide for picking the “best” exercises for you:

• Goal Setting: Match your exercises to your health goals.  If you want to exercise for athletic competition, you will want to perform exercises that match that specific event. For the average person wanting to exercise to live a healthier life, the specifics of exercise are of less importance. For those that do no exercise, a little more of anything is all you need.  Set goals and if you are unable to reach your goals, find a professional that can help you.

• Enjoy it: Find activities that you like. If your brain does not like something, you simply will not do it the rest of your life. One golden rule to live by is: Exercise should never cause pain!

• Stick with the three basics:
1. Cardiovascular (aerobic) exercise that will increase your heart rate for a period of time.

2. Strength training exercises targeting specific activities or general movements.

3. Movement activity that moves your body through full range of motion.

• Appropriate stress: The fine line is stressing the body enough for improvement to meet your goals and still enjoying the exercise. This is where many exercise routines go wrong. You apply too much stress leading to burnout or injury, or not enough stress and are unable to make positive changes to meet your goals.

Exercising should be simple and has too many benefits for healthy living not to be done. Don’t let advertisements or people confuse you with exercise babble into not wanting to exercise or spending more time or money on gimmicks you don’t need. Remember good health should be inexpensive and easy; injury and illness will be expensive and difficult.

Got a minute?

Here is a link to a news release about a study showing that sitting docs have happier patients.  The simple act of sitting in a patient room instead of standing in the doorway gave the patients the perception that the doctor spent more time with them and increased the patient's satisfaction score of the doctor.  The interesting thing was that the sitting doctors actually spent less time than the standing doctors.  A patient"s perception is the reality that us in health care need to remember.

It reminded me of information I had learned from a lecture by Peter R. Kovacek, MSA, PT.  He talked about the importance of being a productive therapist with your patients and to not let distractions interfere with your treatment (like phone calls, staff, or other patients).  When comparing the productive therapist to a lesser productive therapist in his studies it showed that the productive therapist would spend less time with the patient, but the patient perceived that they spent more time them.  While the converse was true for the lesser productive therapist who was more apt to let distractions interrupt the patient treatment time, the therapist spent more time with the patient, but the patient perceived that the therapist spent less time with them.

In today's busy health care environment it often seems like there is not enough time to spend with our patients that we want too.  We often feel rushed and let distractions get in our way.  But if we take a minute and sit down to truly listen to the patient and what their story is and manage our environment to limit distractions, we might find that we can spend less time with the patient, while giving the patient more of what they need.  Sounds a lot like a "Win-Win" to me.

So if we remember the primary things a patient wants during the initial visit:

1. What is wrong with me?
2. How long will it take to get better?
3. What can I, the patient, do?
4. What can you, the physical therapist, do for me?

If we sit down and answer that info for them, we are often starting down a path that is centered on the patient which will help lead to a positive outcome for the patient.

Share any stories of when you noticed a health care provider "sat and gave you a minute" or when the opposite happened and they "stood and gave you a second".  Offer ways that you make sure you "sit and give the patient what they need".

Too many options to change?

I just got done with an excellent book – Switch: How to Change Things When Change Is Hard. It is about how to help you create change things when change is hard.  One point that I thought was interesting and very true is that often when it comes to change we don’t give enough detail to help others with change.   We give vague answers to the questions others have and nonspecific direction to take when it comes to helping them get through the emotional and cognitive changes needed to make the change.   Let me give an example that is probably all too common in health care.  A person sees their doctor and it is finally at that point – borderline high blood pressure, beginning signs of diabetes and cholesterol is too high.   So what happens, usually they are given a blood pressure pill and cholesterol lowering medicine and told they need to eat healthier and start exercising.   I’m sure the first two are specifically given in a prescribed dose with recommendations on type of medicine to take.  The second two are left very vague.  The person probably takes the medicine as prescribed exactly and hopefully tries to exercise and eat better.  But the eating better and exercise probably go by the wayside after awhile.

Does exercise and eating right not get followed up on because people don’t want to do them, or because they don’t know what to do?  The book Switch detailed an interesting study:  There was a jelly stand in a supermarket.  One stand had 6 jams to pick from, the other 24.  People bought more from the jam display with 6 items compared to the stand with 24 items.  There were too many choices with the 24 item stand, and we go through “analysis paralysis” and just choose not to get anything since it is too hard to pick with so many options.  So do people take their medication since it is specifically directed in one way to do it, where as eating right and exercising has a few million options?  It is an interesting thought, to think about.

Just think if the patient was told to go to the drug store and get a couple of medicines with no direction, would they do it?  What if they were given specific guidelines on exercise and a precise diet to follow on a daily basis, would they be more likely to follow?

I love this quote I picked up from a therapy conference from my good friend and fellow Physical Therapist Mike Muffenbier: “Study principles not methods, a mind that can grasp principles will create its own methods.”  I use this often, as I want to understand the principle of how an exercise works or a specific mobilization or facilitation technique in therapy and not just blindly use it.  I need to understand the science principles behind it, so I can expand its use to the patient’s specific needs.  But I am now seeing I have been guilty in the past, maybe not helping my patients, because I might have overloaded them with tweaks to exercise to show them they can create hundreds of exercises from a few basic ones with utilization of Tweakology^TM principles I have learned.  I now see that might be like being at the jam stand with 24 options.  If they do not understand the principles, I need to keep the methods easy to follow.  Especially since in today’s current health system I do not get to follow up as I would like and continually progress a patient’s exercise program appropriately.  Yes learning all the various tweaks is maybe better for you (24 options), then just a couple of exercises (6 options).  But if this increases the chance of the patient making the change and doing the exercises, 6 of them, is better than 24 they do not do. 

It's hard for many exerciser's or those that want to start to exercise with so many exercises to pick from.  But we have to understand where most people are, which is lost in the endless sea of exercise options without knowing what to do.  This causes "analysis paralysis" and many choose to do nothing.  Our current culture does not help it any, just watch a few infomercials, stop at the local gym or fitness section of a store and you can easily see how most are probably overwhelmed with too many options. Plus ask 10 fitness/exercise specialist and there is a good chance you will get 10 different stories of the "best" exercise plan. Which is best for me? How do I know how much and what type to do?  This one says it is better because it burns more calories, but this one builds more muscle, which is better?  Or do I need both?  What if I have a problem with this or that, can I do this or that exercise?  Do I need a fancy machine or is one trainer DVD better than another?  One can easily see "analysis paralysis" setting into the brain and the brain choosing to not do any of it.

The truth is that pretty much all of them are good we just need to move.  You need to follow the basic guidelines:

• stretch daily (a good Physical Therapist can show you 4 or 5 stretches that are best suited for you and your current fitness status)
• cardiovascular exercise 5-6 times a week for 30 minutes at moderate intensity (this should be an activity that you enjoy - walking, biking, swimming, etc.).  If  30 minutes is to long, start at whatever level you feel safe to do and add 2 minutes each week, until you can do 30 minutes.  Moderate intensity is a pace that you can do without becoming short of breath, but still notice that you get a little tired at the end.  As you can see this is a little different for everyone.  To go to higher intensity or time make sure you gradually increase with the help of a physical therapist.
• Strength training 2-3 times a week.  Do some basic total body and core strengthening exercises appropriate for your fitness level.  Again look to get some help from a physical therapist to set you up with a simple program that can be done in about 15 minutes.

This is a great basic exercise plan that will serve anyone well to improve their health and well being.  But you should consult an exercise expert like a physical therapist for some guidance if you have any medical concerns or want to expand your workout further. You wouldn't go into a drug store and just take medicine without a proper frequency, intensity, time and type without consulting your doctor and pharmacist, exercise should be looked at the same.

So do you sometimes wonder how much or what type of exercise to do?  Does it cause some "analysis paralysis" with you?  My fellow PT's, additional thoughts when helping set patients up with exercise programs?

It might not be just about fixing parts

There was a great segment on Good Morning America about back surgery this week, for those that didn't see it, here is the link - Back Pain Relief.  This patient is one of unfortunate millions in the world that suffer with chronic persistent pain.  I have the fortunate opportunity to be at course this weekend Explain Pain, presented by Adriaan Louw, a PT right here from Iowa (that's kinda cool, at least to someone that lives in Iowa).  It is based on the book Explain Pain by David Butler and Lorimer Moseley.  I have mentioned this book previously in a post Back Pain - Now What.  If you treat patients that have pain, or are a person in pain, I highly recommend this book.  It will help explain the biology behind pain, and if you really like this stuff (as I do) then this course is one to look at attending as well.

I will get into some of the mechanics of pain in future posts...but for now I want to pose some questions and thoughts.  As a Physical Therapist I was taught that there are very specific mechanical problems that are the cause to all injuries that we treat.  Don't get me wrong there is, but there is more to it than that as I have learned since graduating over 15 years ago.  We as human beings are an amazingly complex system (and we understand a lot of it, but by far not all of it).  Sorry to burst anyone's bubble that their doctor or physical therapist or whatever healthcare provider you see does not have all the answers.  If they say they do, my advice - RUN!!!!  Let's take a simple look at the body: There are just over 200 bones in the body.  Each of these bones come together to form joints, about 250-350 total depending on how you classify them. They are held together by multiple ligaments at each joint area.  The joints are moved and also held together by muscles. We have around 500-600 of them in our body, again depending on how you classify them.  These muscles are controlled by our nervous system.  It is just a little more complex, we have about 100 billion neurons (give or take one or two) in our brain controlling these muscles, along with all the other systems in our body.  Each of these neurons makes around 5,000 connections with other neurons to communicate all that we do.  Each connection is controlled by a multitude of neurotransmitters and other substances.  I apologize to the anatomist and neuro-scientist for this simple explanation, but I think that you get my point - it is pretty complex.  This amazing system allows us to function in our continually changing world we live in, hopefully in perfect harmony.  I like the analogy of a symphony, that our body plays a beautiful tune when everything is just right - it just happens to have more instruments than particles in the universe.  How cool is that!!!

So, when someone tries to tell you that they can fix your pain with just a fixing one thing as this women in the clip thought was lead to believe, be careful.  Again hear me closely, I am not saying that it may not help with your pain and fix a mechanical fault, but it could very well be due to more than one instrument not playing the right tune.  And the instrument you fixed may not necessarily be the right instrument.  But do not despair either and think if surgery or a drug or therapy can't fix me who can?  Realize your body heals itself every day and you usually don't have to do anything.  Have you ever got a paper cut on your finger?  Is it still there?  Did you have to put any thought into how to fix it?  Your body did it all on it's own, pretty cool!  Yes we might improve the environment a little with a band-aid and some triple antibiotic on it.  So does that mean I never need surgery or need to go to a doctor or physical therapist to help me recover from an injury?  No, not exactly, sometimes we need to help improve that environment for the healing to happen so something wrong does not happen and not allow the body do what it was designed to do.  But just something to think about...fixing something mechanically may not be the end to your pain.

We often compare our bodies to machines.  I do this often when educating patients to understand mechanical deficits that may be contributing factors to their pain.  (Realize I said "contributing" not "causing").   But as humans our bodies are far more complex than any machine.  Does anybody have a car or any other machine that repairs itself?  How about that has logic, reasoning and emotions?  Our body is far more complex, so fixing a broke part by replacing it, taking it out, strengthening it, stretching it, or giving it a drug may not be all it needs.

So what's everyone's thoughts?  Can we or should we be able to "fix" everything by working on the mechanical parts?  It may be a different way of thinking for some of you, but I think we need to make changes to truly help so many people in pain.

Expert Practice

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I had a great opportunity to attend the Advanced Clinical Instructor Education and Credentialing Program through the APTA.  One portion that I really enjoyed was going over a few studies that looked at Expert Practice in Physical Therapy see here and here.  It made me look at myself to see if as a clinician was I working toward becoming an expert physical therapy practitioner.  Hopefully the other health care practitioners reading this will reflect on their own practice to see how they measure up.  If you need a health care practitioner, check to see if they measure up, if not you may want to look for one that does.

Common things found in many clinicians that did not differentiate average from expert, as one may think, were things like:  having a certain number years of experience or working specifically in a specialty area, caring for their patients and commitment to professional growth, and utilization of opportunities for continuing education.  While these are good qualities they did not differentiate an average clinician from an expert clinician.

What they found was what they labeled a Patient-Centered Approach in Expert Clinicians.  This is when the clinician made sure the patient was an active participant and the therapist primary goal is to empower the patient.  This was done through collaboration between therapist and patient through patient education and establishing a good patient-therapist relationship.  The expert clinician shows a high level clinical reasoning that is centered around patient needs.  They use their strong knowledge base along with skills in differential diagnosis and continual self reflection.  This knowledge base is grounded not only in academic knowledge but field experience in other areas outside of physical therapy.  Their knowledge is also used extensively with the use of movement observation.  The expert practitioner has a love of clinical care with non-stop inquisitiveness about life long learning.   They also have amazing humility even with their high level of expertise.  Their patient clinical style is one that patient education is central to their practice.  They individualize their treatment interventions to the patient, you will see every patient getting a different treatment based on evaluation of patient needs body, mind and spirit.

I have started reflecting more before, during and after each patient intervention to see if I am moving more toward patient-centered care approach.  I having been trying to keep in mind a few quotes when setting up patient intervention treatments:

• "Everything should be made as simple as possible, but not simpler." (Einstein)
• "You know you’ve achieved perfection in design, not when you have nothing more to add, but when you have nothing more to take away." (de Saint-Exupery)

So what are you challenging yourself with to become more of an expert in your practice?