Observations in Practice: From Outpatient to the Home

I haven’t written a formal post for a while and that is because I have been engaged in several new projects, including a position providing Homecare Physical Therapy.   While this is a large change from the outpatient/chronic pain setting, my brain has been spinning with thoughts and observations regarding pain, motor control and the living experience.   Here a couple of thoughts and empirical observations that have been made among environments.
Motivation is likely the primary determinant in predicting outcomes—regardless of setting.
In an outpatient setting, I often saw individuals who sought my care upon their own free-will, as well as those who were required to see me (workers compensation).  I observed those who sought my care, required a lesser number of visits to achieve their goals.  I suspect this is likely why individuals who are injured at work may be seen as “malingerers”.  But who are WE to blame the patient?  We should instead blame those who have taken an operational approach in determining a care plan.   If someone is referred to receive my care, without an expectation for recovery from what I do, or with an expectation that I could make them worse, I can almost be certain they will not improve.  But I do not believe this is intentional by the patient.  I suspect it is a lack of understanding from the current referral networks which exist in the workers compensation field.   What would happen if we instead gave more options to the patient?  If we interacted with their views, understandings, motivations and expectations?    I for one would suspect outcomes would improve (in a more timely fashion) and the amount spent on care would decrease.  It comes down to the motivation and beliefs of the individual.
In the home care setting, I am observing a similar phenomenon.  I am currently interacting with individuals who range from almost-independent to completely dependent, as a result of various diagnoses from Parkinson’s to dementia.   I am observing those who are motivated to improve, are the ones who improve.  Even if the patient has dementia, if I can find a way to engage with their nervous system, and motivate them to do something, a change is possible.  Movement does not improve outcomes; Goal oriented movements improve outcomes.
This leads to my argument that motivation is a required variable of motor control.   When we move within our external environment, we do so with a goal in mind.  We move instinctively and as a whole, to achieve this goal; we do not move as individual segments.  For example, when I wake up in the morning, I instinctively sit up, put my feet on the floor and stand.  I do not consciously  think about what to contract.  This is important.  As therapists, we often get caught up in the process of teaching individuals to contract muscles individually because we think it will correlate to function.
Our brain likely prepares and plans differently for each goal-oriented movement, so should we be spending so much time emphasizing localized muscle activity or global?  Does core strengthening translate into work performed by a coal minor?  Will the motor planning and output to perform a quadruped activity translate into lifting a heavy box?  Should I be making an injured worker, with low back pain, get on all 4’s and lift their arms and legs?  Does this make sense?   Not sure…
 It’s OK to be uncertain
This is a difficult thing for anyone, in any profession, to accept.  We hate to admit we are “uncertain”.  We like to be certain that “getting on all 4’s will help you co-contract the tA and multifidus which will help with local spinal stability while you are working, because your pain exists because the spine is moving around too much.”  This is alot to assume.
We often equate uncertainty with a lack of knowledge.  But as “Doctors” of “Physical Therapy” (as well as those with bachelors/masters degrees) we should know enough to know that we often don’t know.   Do we truly understand why some can bend their knee after a replacement and others can’t?  We may say its due to swelling, soft-tissue tightness, decreased scar mobility, perceived disability, etc. but do we know this is why they can’t bend?   What if it’s due a smudge in the homunculus, of a brain that was overprotective of a knee, due to the development of central sensitivity, from years of OA, prior to the replacement?   I am comfortable enough with myself as a professional to admit, I often don’t know.  I treat individuals and their clinical presentations; not conditions.
What happens if we become “too certain”?
These are just a couple of my recent thoughts…
What are some thoughts and observations you have made recently?  

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  • I often think being “too certain” leads to disappointment in both the patient and therapist. Maybe, more frustration for the therapist. As a grad of an OMPT school, we are pushed to be very specific in our dx. I am a new grad and have found this degree of specificity frustrating and cumbersome. It often takes away my ability to engage with the patient fully and truly listen to them. From a patient perspective, I have come into contact with many that have seemed relieved when I tell them that I am not quite sure what is wrong with them, but it is highly unlikely that they have “cancer.” That is an exaggeration, but I have found in my short time as a practicioner that most patients are often “OK” with me not knowing as long as I can make them think I will try everything I know to make them better. Just some thoughts.

    Jeremy June 25, 2013 6:23 pm Reply
  • Well stated. I wholeheartedly agree. Thanks for the post Joseph.

    Ben Swinehart June 25, 2013 6:54 pm Reply
  • What happens if we become “too certain”?
    We can “blame” the patient for the extra 10-20 degrees of knee flexion they never get after their TKR while we are absolved; we get to sleep well at night “knowing” we did the best we could…but, then again…the ‘certain’ therapist never writes insightful and patient-centered blog enties such as this.
    Nice posting, Joe.

    KeithP June 25, 2013 9:14 pm Reply
  • I believe that when we become too certain we are putting ourselves in a position that we believe that we know already all that we need to, thus forgetting that this is an ever evolving profession and we need to keep up with the evidence.
    Good luck on you new endeavors Joe!

    Francisco Maia June 25, 2013 10:21 pm Reply
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