8 Weeks of Learning?

I recently had a student from a local university begin his first of 4 clinical rotations. For the first time, as a clinical educucator, I had a long list of ideas and thoughts to expose the student to. His responsibilities already include approximately 2 hours of paperwork at night, so if the reading seems light in ‘volume’, that is why.

First off, my objective was to introduce him to the importance of his consideration of the rapport that he develops with each patient in developing a fruitful therapeutic alliance.

August 25 – One Hand Clapping: Physical Therapy in the 21st Century by Barrett Dorko

August 26 – In The Service of Life by Rachel Naomi Remen

August 27 – Therapist as operator or interactor? Moving beyond the technique, by Diane Jacobs and Jason Silvernail

August 28 – Patient-centered communication is associated with positive therapeutic alliance: a systematic review. by Pinto et al

August 29 – Motivating People to Make Changes (Pt 1) by Bronnie Thompson

At this point, we had begun to explain how patients benefit from a positive therapeutic alliance, how they are more likely to make lifestyle changes, participate in exercises at home and feel better about their prognosis…all a result of patient interaction. It was now time to provide him with a model that helped to explain why:

August 30 – Pain and the Neuromatrix in the Brain by Ronald Melzack -and- a video of Lorimer Moseley on youtube titled “Pain. Is it all just in your mind?

September 3 – Evidence for a direct relationship between normalisation of pain cognitions and improvement in physical performance in people with chronic low back pain after intensive education by Lorimer Moseley -and- The Popping Spinal Column, another (this time brief) youtube clip of Lorimer Moseley

The reading took a little bit of a turn here. I had seen a patient the previous weekend while covering for another patient and he would be returning to my schedule for the next 2 days prior to being discharged to an outpatient clinic. The patient was a 55-year-old male status post left total knee replacement. His knee had not been responding well: he had ‘more pain than usual’ and his motion was limited to 60 degrees of flexion. My student has been an aide in therapy clinics before and has a Bachelors Degree in Exercise Science; I asked him what he has usually seen done in the clinic when a patient presents similarly. I wanted him to understand why I would not be ‘cranking’ on this man’s knee.

September 4 – The Effects of Manual Therapy on Connective Tissue by A Joseph Threlkeld

September 5 – Day off for student’s birthday

September 6 – An Introduction to evolutionary reasoning: diets, discs, fevers and the placebo by Louis Gifford

September 9 – Centralisation, Part 1: Mechanical pain, mechanical diagnosis and the Wrasse bite, a blog posting by Louis Gifford

September 10 – Student was buying a car – knew he wouldn’t have time.

So…the student has read about the importance of establishing a positive relationship with the patient. He has also been exposed to a general framework of why that is (the patient is a fuzz ball). Now it is time to start to read about HOW to develop that rapport with the patient and how to communicate with them.

September 11 – Motivating people to make changes (Part 1* & Part 2) by Bronnie Thompson

September 12 – Motivating people to make changes (Part 3, Part 4 & Part 5) by Bronnie Thompson

September 13An Overview of Motivational Interviewing

He has been with me for a few weeks now and I continue to hear language that is not always patient centered and thoughtful. He will sometimes say that he is ‘sorry’ when hearing an unfortunate tale from a patient. He will always ask the patient to do something ‘for him’ – my personal pet peeve. I intend to start to nit-pick not only what does with the patient (he is doing an admittedly good job in this domain) but also what he says and the words he chooses when working with patients. Again, to his credit, he relates well to patients and they are appreciative of his efforts, but it is important to learn that we are NEVER good enough at patient communication.

September 16What is therapy about?, a thread on SomaSimple and Isn’t This A Problem?, a blog posting I wrote about one of his own experiences.

For some quality listening while commuting to and from work, I put this interview of Jason Silvernail by Bret Contreras on CD for him too.

He was sick on September 17th and 18th – no reading assignments for those suffering migraine headaches.

September 19 – “Explain Pain” By David Butler & Lorimer Moseley ( Part 1, Part 2, and Part 3) a series of blog posts by Zac Cupples

September 20 – “Explain Pain” By David Butler & Lorimer Moseley ( Part 4 Part 5, and Part 6) a series of blog posts by Zac Cupples

After much discussion throughout the following Monday regarding the interview of Jason Silvernail by Bret Contreras, my student was surprised by the assertion made by Dr Silvernail that depression is (and I paraphrase) more likely to correlate with low back pain than a positive finding on an MRI. He was wondering where this data came from. Of course, this answer had been answered on SomaSimple a few days earlier by Matthew Rupiper and I was able to point him in the right direction:

September 21 – (Sorry, copyrighted materials – abstracts only) Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain and Three-year incidence of low back pain in an initially asymptomatic cohort: clinical and imaging risk factors.

By now, he has received a significant amount of exposure to the complexity of pain and the importance of establishing a therapeutic alliance with the patient. A few weeks earlier, I had recommended that he read The Patient’s Brain by Fabrizio Benedetti after he graduates and before he starts working with patients to begin to understand how neuroscience accounts for what we really ‘do’ as physical therapists. Of course, to my delight, a recent paper by the same author began circulating online. It was 33 pages, but was a wonderful summary of his book. I broke it up into 3 sections, delivering one section to him daily by email (he received a one day respite on the 24th; he had to document 2 evaluations in that night.)

September 22-25Placebo and the New Physiology of the Doctor-Patient Relationship by Fabrizio Benedetti

On Monday, we had conversations regarding what he has been taught as ‘Nerve Tension Tests’. He was confused by my use of the term ‘Neurodynamic Testing’. Additionally, he found it implausible that someone could feel a relief of distal symptoms in the lower leg that had been provoked by seated knee extension (muscle testing) by increasing cervical flexion. This struck him as counter-intuitive. I dug up an old article/paper from 1995 from Michael Shacklock that helped address some of his questions.

September 30Neurodynamics by Michael Shacklock

He is beginning to feel increasingly uncertain, yet I continue to ask for more specificity in his testing and deeper thought in his assessment. I thought the time was right to slow things down for a night and remind him that he is not alone.

October 1Lost by Barrett Dorko

My metaphors were probably getting old, so I decided to start sharing some of my other favorites. Of course, before I got to one of my favorites (it can wait a day), a newsletter featuring Louis Gifford landed in my inbox. I had to forward it to him.

I also had him contrast everything that he we had covered to date with what his patient’s would likely hear before they met him. To illustrate the disparity, I sampled a thread from a fantasy football message board where a 31-year-old is asking for advice for his chronic low back pain.

October 2How do you educate people about their pain and NOT make them think it’s in their head? by Louis Gifford – and – a thread titled Chronic Low Back Pain from Footballguys.com

Over the weekend, he would have plenty of time to digest this GREAT series of postings from Diane Jacobs:

October 3 – New Treatment Encounter (Part 1, Part 2, Part 3, Part 4, Part 5, Part 6)

On October 7, we evaluated a woman who had visited a therapist prior to receiving a total knee replacement. That particular therapist told her something that (frankly) irritated the hell out of me. That ittitation led me to create a blog posting which prompted an i-quaintance to post a relevant article, both of which I shared with my student:

October 8 – Just Zip It (my own posting) and Linear and Curvilinear Relationship between Knee Range of Motion and Physical Functioning in People with Knee Osteoarthritis: A Cross-Sectional Study by Hoogeboom et al.

From this point forward, the student was carrying an expanding caseload with a large burden of written work to complete ‘after hours’. Additionally, he began having some ‘family issues’ that was preventing him from completing his written assignments on time, so I knew that additional reading was out of the question.

So with that in mind, I gave him his last reading assignment…one that I knew he might never finish:

October 10 – Diane Jacobs ambitious and wondefully exhaustive review of Melzack & Katz’ article, simply titled ‘Pain‘. She began her journey on May 14; it concluded on August 4. It is nothing short of amazing.

  • Part 1 First two sentences
  • Part 2 Pain is personal
  • Part 3 –
    • Part 3a Pain is more than sensation: Backdrop
    • Part 3b Pain is not receptor stimulation
    • Part 3c: Pain depends on everything ever experienced by an individual
  • Part 4: Pain is a multidimensional experience across time
  • Part 5: Pain and purpose
  • Part 6- History of Pain Science
    • Part 6a: Descartes and his era
    • Part 6b: History of pain – what’s in “Ref 4”?
    • Part 6c: History of pain, Ref 4, cont.. : There is no pain matrix, only a neuromatrix
    • Part 6d: History of Pain: Final takedown
    • Part 6e: Pattern theories in the history of pain
    • Part 6f: Evaluation of pain theories
    • Part 6g: History of Pain, the cautionary tale.
    • Part 6h: Gate Control Theory.
  • Part 7 – Gate control theory
    • Part 7: Gate control theory has stood the test of time: Patrick David Wall
    • Part 7b: Gate control: “The theory was a leap of faith but it was right!”
  • Part 8 – Beyond the gate
  • Part 9 – Phantom Pain
    • Part 9: Phantom pain – in the brain!
    • Part 9b: Dawn of the Neuromatrix model
    • Part 9c: Neuromatrix: MORE than just spinal projection areas in thalamus and cortex
    • Part 9d: More about phantom body pain in paraplegics
  • Part 10 – “We don’t need a body to feel a body.”
    • Part 10: “We don’t need a body to feel a body.”
    • Part 10b: Conclusion1: The brain generates its own experience of being in a body
    • Part 10c: Conclusion 2: Your brain, not your body, tells you what you’re feeling
    • Part 10d: Conclusion 3: The brain’s sense of “Self” can INclude missing parts, or EXclude actual parts, of the biological body
    • Part 10e: The neural network that both comprises and moves “Self” is (only)modified by sensory experience
  • Part 11 – A new conceptual brain model
    • Part 11: We need a new conceptual brain model!
    • Part 11b: Intro to a new conceptual nervous system
    • Part 11c: Older brain models just don’t cut it
    • Part 11d: The NEW brain model!
  • Part 12 – Action Patterns
    • Part 12: Action!
    • 12b: Examining the motor system, first pass.
    • 12c: Motor output and nervous systems – where they EACH came from
    • Part 12d… deeper and deeper into basal ganglia
    • Part 12e: Still awfully deep in basal ganglia
    • Part 12f: Surfacing out of basal ganglia
    • Part 12g: The Action-Neuromatrix
  • Part 13 – Neuroplasticity
  • Part 14 –
    • Part 14: Side trip out to the periphery!
    • Part 14b: Prevention of pain neurotags is WAY easier than cure
    • Part 14c: PW Nathan was an interesting pain researcher
    • Part 14d: Brain glia are from neuroectoderm and PNS glia are from neural crest
    • Part 14e: The stars in our heads
    • Part 14f: Gleeful about glia
    • Part 14g: ERKs and MAPKs and pain
    • Part 14h: Glia-fication of nociceptive input
    • Part 14i: Molecular mediators large and small
    • Part 14j: Neurons, calling glia (over, do you read?)
    • Part 14k: Glia calling glia, over. Do you read?
    • Part 14l: Satellite cell and neuron cell body interactions, and we’re outta here!
  • Part 15: Prevention of neurobiological hoarding behaviour by dorsal horn and DRG glia is easier than clutter-busting after the fact
  • Part 16: Apples are to fruit as cows are to animals as nociceptive input is to pain
  • Pain and Stress
    • Part 17: The stress of it all
    • Part 17b: Stress and adrenals
    • Part 17c: Women, pain, and stress
    • Part 17d: Stress, aging, and pain
    • Part 17e: Stress and aging, keeping hippocampal dendrites fluffed up
    • Part 17f: Chrousos and Gold and stress
    • Part 17g: Stress conceptualization through the ages
    • Part 17h: Phenomenology and physiology of stress
    • Part 17i: Pathophysiology of stress
    • Part 17j: Cortisol, good or bad? Sensitivity to pain traumatization.

And then it was over. His 8 weeks were complete. Some things he read, some he ‘glanced over’, some I am pretty sure he didn’t read at all. Regardless, the opportunity was there to learn something; I can only hope that he did.

*this was re-introduced as the student neglected to read it the first time

2 thoughts on “8 Weeks of Learning?

  1. Keith-

    Well done. A great resource for me as I start taking on clinical students. My first one was exposed to all this early on so it was nice, but my next one has no clue most of it exists. I fear they are too entrenched in the status quo, filled with postural/structural nonsense and eager to break out their goniometer and special tests. How was this all received by your student? Did they feel you were trying to change them? Were they open to alternative beliefs? Did the conversation ever arise where you questioned their current institutional education? I’m looking forward to using this stuff to open their eyes a little bit more, I just hope it is not in vain.

    Nice blog-
    Chris

    • Hi Chris, thanks for reading.

      How was this all received by your student?

      I think the best way to phrase it would be ‘tolerant’. Not necessarily enthusiastic, but every once in a while there was an ‘a-ha’ moment. This was especially true with the podcast with Contreras/Silvernail. In fairness, my student is ortho-driven and hasa BS in Exercise Physiology, so the podcast really struck a nerve with him and helped to explore how some of the other readings had more application in what he will do in the future.

      Regarding the interaction stuff…I think he began to see the light, but I don’t know if he was just placating me or if he really found value in what I was trying to show him.

      Did they feel you were trying to change them? Were they open to alternative beliefs?

      When I first met him, he said, “I haven’t spent extra time reading stuff on pain…I figured I already knew enough about that.” [yet he has an interest in FMS]. This was a blessing and a curse. The blessing was that he was an clean slate regarding his thoughts on pain.

      Did the conversation ever arise where you questioned their current institutional education?

      This was not the issue. I understand that there are at least 2 instructors/professors who are well-versed in pain science (I have had the occasion to email or meet them); the problem is that they only have so much time to prepare students for the licensure exam. At this time, I see it as my responsibility in the clinical setting to provide this experience until the licensing exam can change as well. The academic institutions, to a large extent, have their hands tied.

      Meanwhile, they have a professional behaviors class, but this is often considered by students to be a ‘fluff’ course while the ‘meat and potatoes’ courses tend to deal more with anatomical stuff. My experience is that students cannot appreciate the need for a therapeutic alliance until they have more experience in the field (beyond reading textbooks and studying for exams).

      I’m looking forward to using this stuff to open their eyes a little bit more, I just hope it is not in vain.

      Good luck, Chris! All you can do is lead a horse to water…hopefully they don’t sneak a few sips of Kool-Aid along the way when you aren’t looking.

      -Keith

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