Pain & Torture (P.T.)

The thing that has made me lose heart is that this kid is still too frightened to run; in spite of all the education and the movement refreshment she has engaged in; all my coaxing is useless. Because, what she remembers is her ‘back is broken’ and that she has to keep her core tight…*sigh*. It is more than a ‘meme’ problem… it’s the tsunami of bullshit I have to swim against to try to convince her that she’ll be ok…She’s a girl in mid-adolescence; previously athletic, somewhat perfectionistic, high academic achiever and somewhat anxious.

She and I are dealing with the complexity of that – and I have the easier job; she’s still a kid.

I recently received the (above) email from a friend, also a physical therapist. We have communicated with one another on various social media platforms for the more than 3 years. I have never had the pleasure of meeting them in person, but fancy them a strong and informed thinker, as well as a passionate therapist.

My friend, however, is becoming disillusioned and frustrated – overwhelmed by a “tsunami of bullshit”, they are starting to ask themselves, “Why?”, and “What difference can I possibly make?”

Earlier in the email they explained:

She is an adolescent who has been experiencing low back pain for about a year. When I saw her, she had next to no mobility in her trunk. A combination of (1) doctor shopping because of her parent’s fixation with a biomedical cause and a ‘cure’, (2) an orthopod who gave her the spondylolisthesis (Grade 1) diagnosis without much more explanation, or telling her that it was essentially stable, or not altogether life-limiting, and (3) each physical therapist (there were 3 before me) she saw giving her some combinations of ‘core stability exercise’ or ‘clinical pilates’ without bothering to try to fit that into normal, everyday movement and physical activity requirements…they had petrified her into co-contracting her abs and paraspinals until she was stiff as a board.

Somewhere, there is a physical therapist telling yet another girl that she “can’t move that way anymore; it isn’t good for you.” She might feel better for a while and not schedule any additional visits; the physical therapist is validated. Of course, she might stop attending therapy altogether if it isn’t working, but the physical therapist won’t remember her then. No, it would seem that every girl with similar symptoms is going to hear a similar story with the same ending: “You can’t move that way anymore…

I am reminded of something that I read earlier in the week – a thought and a vision that has stuck with me. The passage is from Albert Camus’ The Fall:

To be sure, you are not familiar with that dungeon cell that was called the little-ease in the Middle Ages…That cell was distinguished from others by ingenious dimensions. It was not high enough to stand up in nor yet wide enough to lie down in. One had to take on an awkward manner and live on the diagonal; sleep was a collapse, and waking a squatting. Mon cher, there was genius—and I am weighing my words—in that so simple invention. Every day through the unchanging restriction that stiffened his body, the condemned man learned that he was guilty and that innocence consists in stretching joyously.

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Keeping House

She leaned over the railing from above, after already walking halfway down the stairs. “I am done making one bed, Daddy,” she said, “but I still have one bed to make.”

“Whose bed do you have to make?” I asked.

“I need to make Woof’s bed.”

[Brief backstory: Tori is very much into small stuffed toys. Every night for about 2 months, her favorite owl, Hootie, was tucked into a small dollhouse bed adjacent to her own and covered with an even smaller blanket. In the last couple of weeks, Hootie has lost his bed to an aptly-named stuffed dog.]

“I thought that was Hootie’s bed,” I said, purposefully antagonistically.

“Daddy, Hootie is awake at night…he is an owl. They hunt at night.” [Thanks Wild Kratts, for helping teach her about owls]

“Then you don’t have to make the bed after all. Hootie must be tired after not sleeping last night; you can just tuck him into the bed, instead.”

“Huh…” she said. She looked down to the floor, silently gazing into (otherwise) empty space for what seemed like 6-8 seconds. She was frozen in thought, perhaps even contemplation. How was she going to integrate this new (reasonable) information into her plans for this morning?

“I’m almost done making the beds, Daddy. [she turns to run up the stairs] I’ll be right down in a second.”

I laughed…I often witness the same thing in the workplace too.

Can’t Get Clean

The network is stepping up its game.

They have elected to participate in a pilot program with the state-funded (and federally subsidized) Medicaid insurer, whereby they will no longer charge the state on a fee-for-service basis. Instead, they will receive a single bundled payment for an episode of care that will last from the date of the patient’s hospitalization through the end of the third month of the patient’s care. Essentially the insurer is incentivizing the network to provide quality and cost-effective care; if they are successful, the network gets to keep a portion of the savings. The problem in implementing such a plan is this: the Medicaid population is (historically) the sickest and least “compliant” population with the greatest number of comorbidities. In short, the Medicaid population features the network’s most complex patients.

“All we are doing is spinning our wheels deeper into the mud,” I said. We all know that the strongest risk-factor for nearly each costly condition in that population is the exact reason (which we have no influence over) that Medicaid is their insurer to begin with: they are poor,” I said to a colleague.

“Yeah, but they keep making their own bad decisions…what are ya gonna do?” he asked.

“How can you expect an individual to make decisions that mirror your own values when they are raised in a hopeless environment built on a foundation of inherent inequality? This reminds me of a conversation (last year) that I had with my grandfather (an old “southern gentleman”) and my father. My dad is a right-leaning would-be Trump voter who is quick to complain about how folks won’t pick themselves up by their bootstraps, how communities don’t take their streets back from gangs, and fails to understand why many people in the urban community don’t value a high school education. My grandfather was sharing an experience that he had when walking downtown in the mid-nineties when he walked by the soup kitchen. The line was out the door and he vividly remembers a teenager standing in line with a small boy; he thought to himself, ‘With that boy as a father, this kid doesn’t have a chance.’ My father raised his hands in frustration, ‘See? Exactly!’ he said. ‘This is what I am always talking about…they are just takin’ my money without workin’ a lick, and then their kids don’t learn how to do shit, either.’ [my colleague nods his head in agreement]. To which, I turned to my father and said, ‘Yeah, but [assuming that the teenager was a father and not a sibling – which I took issue with] if your assumptions are correct, then when you walk by that same soup kitchen today, that boy who didn’t have a chance almost twenty years ago has now grown up and may be in the same line with a child of his own. If he didn’t have a chance back then, why do you look down on him today?'”

My colleague looked at me in the eye and grinned: “That’s why I’m all for population cleansing.” My eyes widened. “Hey – keep in mind – I said ‘population cleansing’, not ‘ethnic cleansing.'”

Perhaps it was just an unfunny joke, but I preferred my father’s response: “Jesus christ, Keith, you know it’s more complicated than that.”

My father wasn’t funny, but he was right. It’s way more complicated than that.

A More Humanistic Lens

A few weeks ago, you purchased a digital single lens reflex (dSLR) camera for the first time. You were excited about all the pictures you were going to take – they were going to be way better than those pics you were taking with your cell phone.

Of course, there was a bit of a learning curve with all the buttons, settings, and adjustments, but after exercising your Google-fu and practicing a bit on your own, you learned quite a bit in a relatively short time and you are a bit proud of yourself. You aren’t a master photographer quite yet, but you have quickly learned that there is a relationship between a camera’s:

  • focal length: the ‘35’ in a 35mm camera; the larger the number, the greater the zoom, and the greater the distance between the image sensor (‘film’) and the aperture
  • aperture: a measure of how big the hole in the lens is, the hole allows light to pass into the camera. Measured in a fraction of the focal length (e.g. f/3.5), the larger the aperture number, the smaller the hole that the light passes through
  • shutter speed: the amount of time the camera lens allows light to enter the camera, usually measured in fractions of a second
  • ‘film speed’: perhaps you remember going to the store to pick up 200 ISO or 400 ISO film for everyday use, before the advent of digital photography…the larger the number, the more light sensitive the film (the values are standardized by the International Standards Organisation, thus ISO)
Fig 1. The cat in the foreground is overexposed.

Fig 1. The cat in the foreground is overexposed.

You have been tinkering with the dSLR for a few weeks now, and you have a pretty good feel for things. You have come to realize that there is an ideal amount of light that needs to strike the image sensor (virtual ‘film’) to create a good picture. If too much light strikes the sensor, the picture will be over-exposed and will appear too bright (Fig 1). If too little light strikes the sensor, the picture will be under-exposed and will appear too dark (Fig 2). You now appreciate that the lighting in your environment dictates the ISO you choose (200-400 for daylight, 1000+ for low light conditions – but be careful, the more sensitive the ISO, the worse the noise). You realize that if your subject is moving, you need a faster shutter speed so that the picture isn’t blurred. You understand that a faster shutter results in less light hitting the sensor, so (in that instance) you would need to compensate by increasing the aperture size (ironically adjusting the value smaller, because it is the denominator of a fraction, whose value you wish to increase).

Fig 2. The building is underexposed.

Fig 2. The building is underexposed.

Now imagine for a moment that you just purchased a new lens for your dSLR camera. The lens that you received with the camera (often referred to as your ‘kit lens’) quickly proved to be inadequate (you think) and you needed to upgrade so that you could take pictures with more flexibility than was afforded you by the simple 18-55mm f/3.5-5.6 lens you have been using. Some folks will go to a reasonably priced prime lens as their first lens purchase, but many (like yourself) decide to go with a bigger ‘zoom’, so they obtain what is termed a ‘telephoto lens’. In this instance, you have selected a lens that should work in most instances under typical lighting conditions: an 18-300mm f/3.5-5.6 lens.

If you are not a photographer, perhaps it would instead be easier (at this point) to imagine that you have just graduated from PT school and you realize all too quickly that – while you are now licensed to practice – your skills seem inadequate; you are not helping as many people as you may like, so you elect to go to a continuing education course. The course is designed to hone in on a certain aspect of your care and improve your expertise in that specific area. In doing so, you are improving your ability to ‘zoom in’ on a subject/patient. In other words, you have the basic know-how to operate the camera, but increasing from 55mm of available focal length to 300mm feels like completing the first 4 courses of a certification program – only (for $800 USD) the lens is considerably cheaper and is likely to bring you greater pleasure.

In many instances, though, while the telephoto lens helps you take pictures of things in the distance (i.e. birds or your kid playing a soccer game), you will quickly discover that the telephoto lens has limited utility. The farther you zoom in, the darker the picture becomes – the mechanics of the lens dictate that the aperture can move no larger than f/5.6. To compensate, you need to increase the ISO, which adds more noise to the picture. You could avoid adding noise by reducing your shutter speed, but now there is likely going to be increased motion blur in your picture. And then there is the issue with perspective…

What about perspective?

If you take a picture from the same angle each time, how can the perspective possibly change if it is taken with one focal length versus another?

Compressed

Fig 3. Compressed Skyscrapers

Firstly, the picture taken with a telephoto lens will appear compressed or flattened. Look, for instance, at Figure 3, a photograph of skyscrapers which appear as though they have been built atop one another when photographed with a 300mm focal length. It is a neat effect in the photo, but the loss of depth is undeniable and often undesirable.

Secondly, the background of the subject photographed with a 300mm focal length from a distance is narrow; it is physically incapable of capturing the surrounding environment (see Fig 4).

Meanwhile, if you wish to photograph a subject in their environment, capturing context, you need to use a smaller focal length. You need to move closer to the subject, much closer. With a shorter focal length, the larger (f/3.5) aperture is now available so more light can come through the lens. With more light available, you can adjust down the ISO, reducing the noise in your picture as well. The closer you get to your subject (with your wide-angled, 18mm focal length), the brighter and clearer your picture can become and the greater your field of view.

Fig 4. The left photo on the left is taken with a telephoto lens from a distance, the photo on the right was taken with a wide angle lens from close up

Fig 4. The photo on the left is taken with a telephoto lens from a greater distance, the photo on the right was taken with a wide angle lens from close up

Of course, then you realize that your kit lens could shoot at 18mm too. Sure, every once in awhile, you may find a use for the 200mm or 300mm focal lengths, but (for the most part) you could have saved $800 and mastered the kit lens, instead. There are occasions when the extra focal length may be helpful, but you will not rely on it every day.

.   .   .   .

In a competitive marketplace where every continuing education purveyor is trying to get you to buy their special telephoto lens – each with its own special features – consider honing your skills with the kit lens first and foremost. The small focal length on the kit lens is what encourages you to stand closer to your patient and develop a relationship. Moving closer to your patient helps clarify the picture you are trying to capture; it reduces the noise. The different/closer perspective affords you the opportunity to see more variables that surround, stress, and influence a patient embodied in their unique environment with its particular circumstances.

Fig 5. A telephoto view of the patient

The telephoto lens encourages you to zoom in on one area, only to zoom out and back in on another. The telephoto lens directs us to look at the parts, in isolation. It is the telephoto lens that separates the biological from the psychological from the sociological. The telephoto lens has fractured and fragmented our patients. The world is filled with clinicians with 300mm lenses – far fewer have mastered 18mm.

My only question: can you be a wide-angle PT?

Fig 6. A wide-angle view of the patient

Fig 6. A wide-angle view of the patient

Passive Listening and Therapist-Centered Care

She had 2 falls yesterday, after the surgeon had told her that she can start putting more weight on her foot; after a month of toe-touch weight bearing, the x-rays had (apparently) looked good. She denies any pain, which is (hopefully) a good thing, considering her hip has already dislocated twice in the last month.

“Did I dislocate again?” she asked.

“Did your hip have pain when you dislocated last time?” I asked.

“No,” she replied, “but it hurt like a mother fucker going back in.”

I asked her to lie on her back; she actively moved from sitting to supine independently, without difficulty. Upon assessment, her hips were not overtly asymmetrical; her motion was within restricted limits (considering her dislocation precautions) and she was still pain-free.  She actively flexed/extended her hip without pain, but when she fully extended her hips/knees I noticed the obvious, “When you went in for surgery, did you have a leg length difference?” I inquired.

“Oh sure, I had a shoe with a big honkin’ sole and everything,” she told me. Phew. “Do you mind if I see it?”

She didn’t and kindly directed me to where I would find the shoe on the floor in the other room. As I was scanning the room, looking for the shoe, she yelled from the other room, “I hate that thing.”

“I can imagine that you would,” I replied.

I brought the shoe out to the living room; it was still a pretty good match for her present leg length discrepancy post-op. I wondered aloud if, by trying to walk with a flat foot yesterday (without a lift) she was compromising her balance in a way that may have contributed to the falls. With my gaze focused on the knuckles of my thumbs over her medial malleoli, I said, “I’ll just ask that we try that shoe on for a second to see if it is still successful in evening out your leg length discrepancy.”

Then she wept…uncontrollably.

She really hated that shoe. I should have asked why.

Hyperbole?

half glass full: we are living each day – hopefully to its fullest potential

half glass empty: day by day, we are all dying slowly (some faster than others, some more predictably)

.    .    .    .

I get it. This is not going to resonate with everyone (anyone?). My typical patient has multiple comorbities, is incapable of leaving their home due to challenges with their mobility and has varying degrees of pain (often not their primary complaint). They are weak, alone and (often) depressed. They are scared and fearful of the uncertainty that awaits them. This is not everyone’s typical patient, but it is mine.

As I reflect back on my metamorphosis these past few years from who I was to who I am, I realize that (for better or worse) my way of being with patient’s has been most informed by my working with those with terminal conditions, weeks/months before their inevitable transfer from home- to palliative-care.

Most clinicians recognize that patient’s who receive palliative care deserve a dignified level of care that is often absent in typical settings. This care often emphasizes the clinician’s efforts to gain trust through inter-personal interactions and being present in a relationship that both the patient and the clinician goes in the direction of the other.

What would physical therapy care look like if every PT worked to earn patient trust, rather than assuming it is conferred on them by title, degree or position?

What would physical therapy look like if we interacted with each patient as if they were dying?

Expectations of Actions, Not Results

I recently entered the home of an 88-year-old woman that, as Dr. Kyle Ridgeway, PT, DPT mentions in a recent post, “everyone dreads.” She is ornery – but I would be too. She cannot hear well, yet has no hearing aids, so is shut off from TV, radio and most conversation on the phone – which prevents her from talking with her children who live 3,000 miles away. Most of her friends are dead. She has grown accustomed to living alone, yet now she has visitors daily (strangers from an home care agency) to address venous ulcers. She mentioned that she has had falls in the past, prompting a PT referral which triggered a visit from yours truly. She spent the first 20 minutes of my visit yelling at me about how disgruntled she is with her doctors, the upkeep on her home, the daily intrusions… These are all variables that I have no control over and they will certainly confound any progress that I try to make with this patient, but my expectations need not change. After all, I only have expectations of myself – to simply walk into each home being courteous, respectful, reflective, quiet (when appropriate), and poised.

Before I left her home, I apologized for interrupting her day and openly empathized with how challenging and disruptive my visit must be. She (surprisingly – in turn) apologized to me for being “such a grumpy old lady” – she was now empathizing with me. In one hour, something special had happened: not only was I able to stand in her shoes, but she was also able to stand in mine. We developed something mutual, something to share.

Today, I plan to enter her home gently and to kneel beside her chair again, as I did the first day. I plan to yell at her politely, but slowly, so she can hear me. I plan to let her complain as long as she needs to before steering the conversation toward something that could be recognized as physical therapy. I plan to serve as I can as a purposefully courteous, respectful, reflective, quiet (when appropriate), and poised medical professional. Hopefully, she is willing to give something back and join me again in that space where therapy might happen.

Time will tell – after all, the outcomes are out of my control.