How Should We Treat Hip and Knee Osteoarthritis?

Osteoarthritis: The Gateway Problem?

Osteoarthritis is one of the most common points of entry to the physio clinic. I feel that it’s a “gateway” condition — once people find out that they have arthritis, sometimes they talk as if it’s only downhill, as if their pain and functioning will only get worse.

But “getting worse” is not an option that I want to consider as a physio. So, in this week’s Physio Weekly, we’ll review some studies to help you get the best results with patients with hip or knee osteoarthritis.

Exercise + Pain Coping Skills = Improved Quality of Life

I want to treat the whole person, not just the hip or knee. What is the evidence that we can really improve quality of life for those with osteoarthritis?

A 2018 review explored what types of interventions actually improve quality of life and psychosocial factors for those with knee osteoarthritis. Although the authors found that exercise does improve quality of life, they made no specific recommendations about type of exercise.

One of the most important psychosocial factors for treating OA is self-efficacy — which is essentially the ability to do whatever it takes to accomplish a task. In order to improve self-efficacy in knee OA, there is some evidence that adding pain coping skills training may be more effective than exercise alone. 

In other words, help your patients learn to cope with pain, and get them moving.

Dosing Exercise for Osteoarthritis 

Most of us would say exercise is essential, but what dose of exercise is best? 

A 2018 review of exercise dosing found that at least 24 exercise sessions provide the most benefit, over an 8- to 12-week period. Exercise sessions should be at least 20 minutes.

The benefits of exercise for hip and knee osteoarthritis.

Physical activity is effective at preventing as many as 35 chronic diseases and at treating 26 chronic diseases, including cardiovascular disease, type II diabetes, and depression. Skou et al provide seven key exercise recommendations for those with hip and knee osteoarthritis:

1. Provide aerobic, resistance, performance or neuromuscular exercisestailored and targeted to individual patient needs and preferences.

2. Consider aquatic exercise in patients who are unable to adequately complete land based exercise due to pain.

3. Provide a minimum of 12 supervised exercise sessions of 30-60 minutes per session, over a six week period – i.e. two sessions per week.

4. Encourage an additional 1-2 sessions per week to optimize outcomes, particularly related to strength.

5. Consider extending initial exercise therapy programs to 12 weeks or longer to optimize outcomes, particularly related to strength.

6. Include patient education and consider booster sessions in the long term to enhance adherence and progression.

7. Provide education and reassurance about managing potential pain flares and inflammation, and how to modify exercises and physical activity to ensure continued participation.

Exercise Is the Best Exercise

But wait. When you prescribe exercise for your patients, does the type of exercise matter?

The Orthopaedic Section published a 2017 revision of the clinical practice guidelines for hip osteoarthritis. The guidelines recommend that there is strong evidence for prescribing flexibility, strengthening, and endurance exercises for mild to moderate hip osteoarthritis at a dosage of 1 to 5 sessions per week for 6 to 12 weeks.

But if you’re like me, then “flexibility, strengthening, and endurance” is not specific enough. What kinds are the best?

Recent papers from Bieler and colleagues show how hard it is for one type of exercise to outperform another in hip osteoarthritis. Their 2017 paper examined the differences of 4 months of supervised strengthening exercises vs. Nordic walking vs. unsupervised home exercises. The supervised strengthening exercises included machine exercises aiming for sets at 10 RM. The Nordic walking group included trail walking for 3-4 km to start and progressing distance and speed. The home base exercise group used a chair stand exercise, a pelvic lifts, isometric hip flexion exercise in standing, and a gluteus medius exercise in sidelying.

Which exercise was most effective? 
There were no significant between group differences for improvements in muscle strength and power or range of motion at any time point. The strength training group and the Nordic walking group reported less pain at 4 months than the home-based exercise group. The Nordic walking group outperformed the other two groups at all time points in other functional measures like the 6-minute walk test. However, the Nordic walking group had the highest level of dropout.

I think it is fascinating that the Nordic walking group may have had the greatest results but also seem the least desirable.

Prove the Return on Investment

What performance measures should we use to set goals in hip/knee osteoarthritis?

Master and colleagues found that these three measures predict function difficulties with knee OA:

  • >11.4-14.0 seconds on a 5 times sit-to-stand test
  • <1.13-1.26 m/s gait speed
  • >315-349 seconds on a 400-m walk test

These are good measure to use when you are setting goals with patients with knee OA.

Do backpacks hurt kids? The complexity of pain.

Physio Weekly Brings the Pain!

If you haven’t noticed already, I’m a total pain geek. I love learning about pain, and the research continues to surprise me. Nerdiness aside, learning more about pain helps us serve those suffering from it — and that is what we’re here to do. 

Should the Spine Be Scared Straight?

I remember getting screened for scoliosis as a child and feeling terrifyed — as if having this disease would ruin my life. Teachers banned us students from carrying our backpacks between classes, claiming they were protecting our backs.

But, do backpacks actually cause back pain in children and adolescents?
Probably not. A recent systematic review found no relationship between carrying backpacks and having back pain. Though the American Academy of Pediatrics recommends that backpacks should be no heavier than 10-20% of bodyweight, one study reported that even an average of 19.9% of bodyweight in backpacks still had no association with pain in middle school children.

So, what causes back pain in children and adolescents?
Calvo-Munoz and colleagues published a systematic review of 61 studies that assessed 35 possible risk factors for low back pain in children and adolescents. The authors concluded that the evidence disputes the thought that back pain is related to the number of hours spent sitting, BMI, backpack weight or method, or spine morphology.

Indeed, there isn’t much evidence for any association between scoliosis and pain, with one study following patients for 50 years and still finding no association between pain and degree of scoliosis.

Instead, Calvo-Munoz and colleagues found that involvement in sports is associated with higher likelihood of back pain, and older age is associated with higher incidence of pain, possibly because older children are more likely to play sports at a higher intensity.

The Paradox of Persistent Pain

Acute pain serves obvious purposes. Pain helps us to survive. But what about persistent pain? It doesn’t offer the same survival benefit at all. Instead, it is massive detriment — and the leading cause of disability in the world.

Chronic pain arises from several psychological processes. Steve Linton and colleagues describe four tenets that inform clinicians how acute pain can turn into chronic pain — and what we can do about it.

  1. Chronic pain is a developmental process. Persistent pain is often cyclical and recurrent, rather than simply an acute pain episode that extends beyond expected recovery time.
  2. Contextual cues set the stage. The context of the pain experience can determine the negative (or positive) effects of behaviors, thoughts, and emotions. 
  3. Transdiagnostic processes serve as drivers. There are always other underlying psychological processes that may help or hinder the pain experience such as fear, catastrophic thinking, resilience, or childhood adversity.
  4. The fundamental role of learningClassical conditioning may lead people to associate certain actions or activities with pain, and operant conditioning may reinforce certain pain behaviors or avoidance.

So what can we do to treat chronic pain?

Linton and colleagues assert that the psychology of pain means that we should use psychology in our treatment. “We suggest,” they write, “that exposure training for fear-avoidance or cognitive-behavioral therapy for depression will be more successful than indirect methods, such as analgesics or manipulation, that mainly help to reduce pain” (p. 322).

Do you use cognitive-behavioral therapy in the clinic? Tell us about it in the Facebook group.

The Diagnostic Trap of Widespread Pain

Sometimes it’s easy to fall into a trap THINKING that persistent pain is mostly psychosocial. It’s even easier to discount biological contributions when pain is widespread. What are some of your differential diagnoses when you see widespread pain in the clinic?

A recent case in JOSPT illustrates how our clinical reasoning should consider potential non-musculoskeletal contributions to pain. In this case, a 30 year old woman reported constant pain in her lower back and upper back, with a 15 year history of low back pain. She also reported that pain spread to all four extremities within the previous year. 

Her pain had gradually intensified and the physical therapist’s examination led the therapist to suspect possible aortic abdominal aneurysm (AAA) after detecting an atypical abdominal pulse and constant throbbing pain that was exacerbated by lying supine. The resident’s differential diagnosis included AAA, gallbladder pathology, gastrointestinal pathology, and gynecological pathology. At the emergency department, AAA was ruled out.

After further testing and a diagnoses of symptomatic cholelithiasis and fertilization without implantation, the patient underwent laparoscopic cholecystectomy. Postoperatively, the patient still had low back pain though. Then after another evaluation post surgery, the patient’s back pain fit the pattern mechanical low back pain without any signs of continued systemic contributions.

This paper is really enlightening to me because it reminds the physio that there can be both neuromusculoskeletal and systemic reasons for pain — at the same time. When pain is widespread, it can be easy to suspect central sensitization, neglecting other body systems along the way.

What’s Next?

If you liked this post, then I would love to hear from you! Leave a comment or tweet me @zachrstearns — just use the hashtag #physioweekly.

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Opioids, Achilles guidelines, and Mindfulness

Welcome to the First Physio Weekly!

Thank you for signing up for this newsletter! After years of sharing articles with friends, I’ve made things easier for everyone by starting an email newsletter. To be physios in the 21st century, we need to work together — and that means sharing knowledge, spreading excellence, and learning from each other. 

But this is about so much more than journals, blogs, or tweets…I want you to be the BEST version of yourself, I want to get the best results for our patients, and ultimately, I want to liberate the world from pain. 

So, thank you for subscribing and thank you in advance for your dedication to treating those who are looking for hope.

The Opioid Crisis

You’ve noticed.  I’ve noticed.   Mainstream media is covering the opioid crisis more and more.

The New York Times published a terrific editorial about the opioid crisis.  The article is great in that it talks about what led to this crisis and how it’s another case of history repeating itself. However, the article falls short by failing to promote solutions other than medical management.

What other solutions are there?
Sarah Wenger and colleagues published a paper in the Physical Therapy Journal about reducing opioid use for patients with chronic pain. Wenger and colleagues outline helpful points for physios who care for people using opiods.  Practicioners, like you and I, should watch for opioid use disorder using the “Four ‘C’s”: 

  • adverse consequences,
  • impaired control,
  • compulsive use, and
  • craving.

And what about opiod tapering?
Even though there is no “standard”, “the Mayo Clinic and the CDC suggest a decrease of 10% of the original dose every 5 to 7 days until 30% of the original dose is reached, followed by a 10% decrease of the remaining dose per week for the remainder of the taper.”

Want more resources for those in pain? 
I agree with Paul MintkenJeff Moore, and Tim Flynn, who emphasized the role of education in solving the opioid epidemic. 
In fact, Sarah Wenger developed a program called Power Over Pain, which has an awesome library of resources for those in pain.

Mindfulness… for your patients and for you

Can you improve overall well-being with a mindfullness app?

Bostock et al (2018) published an article showing some fascinating effects of a mindfulness intervention based on a mobile app. After eight weeks of meditation (an average 17 sessions), those who meditated reported a significant improvement in well-being, distress, job strain, and perceptions of workplace social support compared to the waitlist control group.  At 16-week follow-up, positive effects remained for well-being and job strain. 

What I find so interesting is that meditation leads to positive attitudes toward work  — even though the mindfulness intervention did not mention work or the workplace at all. 

In my own life, I like to use apps like Headspace or Calm, so that I get push notifications reminding me to take a quick breather in the morning before clinic… and sometimes in the middle of clinic, too.
 

Looking for more? The Harvard Gazette published a impressive piece about mindfulness meditation that describes not only the evidence about mindfulness but also some guidance for those interested in trying it. 

Achilles’ Last Stand

The May issue of the Journal of Orthopaedic and Sports Physical Therapy includes an update of clinical practice guidelines for treatment of midportion achilles tendon pain. Though the update includes many interesting sections, I am especially happy to see heavy-load, slow-speed resistance training included as an option for exercise prescription.

One example of heavy-slow resistance training that I use often when treating achilles tendinopathy is described in this randomized trial from Beyer and colleagues. In brief, use standing calf raises with a barbell, seated calf raises weighted, and plantarflexion using a leg press machine. Start with 3 sets of 15RM, three time per week, 3 seconds in each direction for the concentric and eccentric phase, then over time phase down the repetitions per set while increasing the intensity.

Other interesting highlights from the practice guidelines include recommending that therapists do NOT use therapeutic tape or night splints, and that due to contradictory evidence there are no recommendations for heel lifts, orthotics, or low-level laser. There is also moderate evidence that adding iontophoresis with dexamethasone may benefit those with acute midportion achilles tendinopathy.

What’s Next?

If you liked this post, then I would love to hear from you! Leave a comment or tweet me @zachrstearns — just use the hashtag #physioweekly.

And if you want more posts like this one delivered to your inbox, consider subscribing. Subscribe to stay on top of the latest research, develop your professional skills, and improve your patients’ outcomes.

Occupational and Physical Therapy, United in Serving Humanity

At the Voice of the Patient, we are dedicated to enhancing our ability as health care providers to truly listen to others and to establish a therapeutic alliance. In some cases, we can benefit from listening to the experience and mindset of other providers, such as Mandy Chamberlain.

Mandy Chamberlain is an occupational therapist and the founder of Seniors Flourish, where she blogs, podcasts, and hosts a learning lab for occupational therapy practitioners. She earned her Master of Occupational Therapy through the University of North Dakota’s School of Medicine and Health Sciences, and decided to focus on Community-Based Medicine. She has a varied clinical background working with geriatrics through home health services, home modification consultation, long-term care, assisted living, inpatient critical access and outpatient therapy services. She now works and consults in the mountains of Colorado.

We talk about how much that occupational and physical therapy have in common, particularly in our mutual desire to serve humanity. We also discuss our shared path to rehabilitation careers through our initial desire to treat mental health. We spend time discussing the importance of the interdisciplinary team and of communication between health care providers. We agree that it’s hard, but we talk about ways to improve the quality of our teams in pursuit of serving our patients.

Check out Mandy’s website: Seniors Flourish. She also hosts her own terrific podcast, also named Seniors Flourish, which is also a member of the Geros Collective. You can follow Mandy on Twitter.

If you have a story to tell as a patient, provider, or both, then contact Zach Stearns on Twitter @zachrstearns or Dave Reed @DReedPT.

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*Find more helpful podcasts & blog posts at http://TheVoiceOfThePatient.org

*Check out the other podcasts in the Geros Collective at http://geroscollective.com

The 3 D’s: Dementia, Delirium, and Depression with Dr. Kenneth Miller

At the Voice of the Patient, we are dedicated to enhancing our ability as health care providers to truly listen to others and to establish a therapeutic alliance. In some cases, we can benefit from listening to the experience and mindset of other providers, such as Dr. Kenneth Miller.

Dr. Miller is a physical therapist and educator with more than 20 years of experience working in home care and inpatient rehab settings, as well as more than 8 years in adjunct faculty roles. He is currently a clinical educator at Catholic Home Care, in Farmingdale, N.Y. He has taught for New York Institute of Technology, University of Michigan–Flint, and Touro College.  He is the co-author of the book Providing Physical Therapy in the Home, published by the American Physical Therapy Association (APTA), as well as the author of peer-reviewed publications in Neurorehabilitation and the Journal of Geriatric Physical Therapy. He has presented at the APTA Combined Sections Meeting and NEXT Conference. Dr. Miller chairs the APTA’s Home Health Section Practice Committee and is a member of the editorial boards of Topics in Geriatric Rehabilitation, GeriNotes, and the Journal of Novel Physiotherapy and Physical Rehabilitation. He is the recipient of numerous honors, including three APTA Home Health Section awards. He is a Board Certified Geriatric Specialist, a TeamSTEPPS Master Trainer, an APTA Credentialed Clinical Instructor, and an APTA Certified Exercise Expert for Aging Adults.

We discuss the role of the 3 D’s — dementia, delirium, and depression. Dr. Miller shares his experience with seeing the 3 D’s in clinical practice as a physical therapist. For any questions or comments, you can find Dr. Miller on Twitter @kenmpt. Dr. Miller also teaches a pharmacology course for GREAT Seminars. 

Resources:

If you have a story to tell as a patient, provider, or both, then contact Zach Stearns on Twitter @zachrstearns or Dave Reed @DReedPT.

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*Find more helpful podcasts & blog posts at http://TheVoiceOfThePatient.org

*Check out the other podcasts in the Senior Rehab Project at http://SeniorRehabProject.com

 

My Mental Health Awareness Month

May is Mental Health Awareness Month. When something is the subject of an “awareness month,” I’m usually pleased at first, because I’m excited to see something like mental health in the spotlight. But wait a second. Wouldn’t it be nice if mental health didn’t even need awareness campaigns? By definition, every single person has “mental health” in some degree, and therefore everyone has a vested interest in mental health prevention and treatment. It’s weird to me that something as ubiquitous as mental health needs more awareness. But indeed it does.

In my profession of physical therapy, for example, we have an interesting relationship with psychology and mental health. On one hand, there is evidence that psychological factors like fear have a huge impact on physical health. We even have screening measures that can predict long-term disability based purely on psychological factors. On the other hand, despite these findings,  physical therapy still has a psychology problem.

I’m finding that some of the problem may be due to the enduring stigma of mental illness. In an attempt to end the stigma of mental illness, my friend Sean Hagey approached Dave Reed and me to discuss Sean’s story and the importance of mental health. We ended up having a conversation that spanned four episodes on the Voice of the Patient. Our conversations taught me a lot about mental health and illness. It’s so powerful to hear about someone’s struggles, and it’s inspiring to see the amount of success and resilience of someone despite their struggles.

If you’re interested in hearing more about Sean’s story, then I encourage you to listen to the Mental Health Matters mini-series of the Voice of the Patient podcast.

  • In the first episode, Sean begins his story, sharing powerful experiences throughout his life.
  • In the second episode, we talk about Sean’s treatment, coping mechanisms, and progress despite challenging times.
  • In the third episode, we talk about the interplay between mental health and his relationships with friends and family.
  • In the fourth episode, we talk about the public perception of mental illness, within healthcare professions and outside of healthcare.

Sean Hagey approached the Voice of the Patient with the idea for this series and has asked that we help to eradicate mental health stigma. Sean wanted to tell his story to bring understanding of patients with mental illness or symptoms of mental illness. Sean is a home health physical therapist assistant in Kansas City, MO, and is the creator of GetPT1st. He recently started a new advocacy program for mental health, Mental Health Matters, which you can follow on Twitter @HopeForMH and on Facebook @HopeForMH. You can follow Sean on Twitter @SeanHagey. Sean has also written several powerful articles on The Mighty. We can continue the conversation and hear more questions from you on the Senior Rehab Project Facebook page by Dustin Jones.

As Sean mentioned in one of the podcasts, no matter how frustrated we are with the state of mental health treatment today, we have come a LONG way over the last few decades. I’m hopeful that we can make even more progress, maybe even to the point of no longer needing an “awareness month” for mental health. Until then, I hope we can keep the conversation going.

3 Things I Would Tell Myself Before Internships

I graduate next month. It feels surreal. I’ve learned so many lessons over the last three years, especially during my clinical rotations.

Going out on internships during PT school is exciting, because it’s time to get into the clinic and — you know — do therapist things. No more Scantrons, very few Powerpoints, but just as many challenging moments. It’s a really interesting metamorphosis from “student” to “clinician,” even though every impressive clinician whom I’ve shadowed has maintained a student-like curiosity that blurs the line between these roles. Before internships, I didn’t anticipate some of the challenges of transitioning from class to clinic.

These are the three most important things that I wish I could go back and tell myself.

1. You don’t know much.

I showed up to my first internship feeling confident — way too confident. I knew that I had done well in class. I was far from perfect, but I was passionate about evidence-based practice and orthopaedics. Since I was heading into a clinic that had a reputation for evidence-based practice in orthopaedics, I was amped. I quickly realized that the role of entry-level education isn’t to prepare us for everything — that’s just impossible. Instead, our education should prepare us to avoid harming the public and to expose us to a big chunk of common conditions. We’ll see a lot of horses, if not that many zebras.

I noticed, though, that my profound lack of knowledge was more serious than a stale animal metaphor. I found that my eagerness to “do therapist things” needed a reality check. This tweet from Justin Scola illustrates my point:

I think I passed “Mount Stupid” during my first internship. I would go back and tell myself to be prepared to be wrong. I would encourage my previous self to ask for other opinions from more experienced clinicians who have already passed Mount Stupid.

I would also caution against beating myself up for being inexperienced. Even though I didn’t feel like an imposter during didactic coursework, I definitely felt it during internships. It’s a scary place to be. Cruz Romero wrote a terrific article about imposter syndrome, and I especially love his advice to adopt a growth mindset and consider moments of inadequacy as signs of growth.

2. Find ways to learn more.

It’s tough to feel like you don’t know much, so the next thing I would say is…try to know much more. Here’s where students can really shine, because we learn about new research in class, have journal access, and have the opportunity to provide in-services. Keeping up with research is difficult, though. Rich Severin wrote an awesome post about ways to stay on top of evidence, and internships are the right time to start healthy evidence-based habits. I used Feedly to keep up with my favorite blogs, and I used Podcast Addict to listen to physical therapy podcasts during my commutes. It was fun to hear PT podcasts that included a student perspective, like the Knowbodies (now new grads) and the Duck Legs Podcast. Twitter and Facebook are always teeming with PT discussions/debates/rants/tweetstorms. I went to AAOMPT and CSM conferences, and I would tell myself to try to go to even more conferences.

Learning is bigger than PubMed, though. I would have told myself to be a bit more adventurous instead of fearing criticism. My clinical instructor during my final internship once told me, “Don’t worry about making mistakes. That’s what I’m here for. I’ll let you know when I disagree.” That advice kind of blew my mind. I am typically pretty terrified of making mistakes, especially when it feels like our clinical instructors might “fail” us for making mistakes. In hindsight, I see now that my CI approached my internship with a growth mindset; he allowed me the chance to learn. I would tell myself to think about how all of my CIs expected me to make mistakes and to learn from them.

Unfortunately, you might not find yourself at an internship with a clinical instructor who wants to mentor you, who wants to help you through your mistakes, or who wants to learn from you. One of my classmates told me that his internship site — a “successful” outpatient clinic — refused to entertain in-services from students. My peer told me that his CI explained it this way: “Your in-service would either be about something that we already know or about something that we don’t care about.” SERIOUSLY? Hearing his story reminded me to be careful about acting like I know anything just because I’ve been reading journal articles. Clearly some CIs and clinics don’t value research literature or DPT education, yet ironically hoard CEUs for taking students without any semblance of a desire for continuing their education. More importantly, knowledge from research evidence is only one aspect of clinical education.

3. Get ready for feedback.

I would then tell myself that regardless of how much (or little) you know, and regardless of how much you learn, you will get tough feedback. I’ve heard stories from some classmates that they had CIs who gave very little feedback. Instead, those CIs kicked back and enjoyed free labor. I never had that type of CI. I had CIs who gave a lot of feedback. I always had formal, weekly discussions about my progress, and I received some type of feedback almost every day of internships. I’m actually thankful this feedback in hindsight, because I know that I’m better for it.

Even so, it’s an emotional challenge to be evaluated, especially if you’re passionate about physical therapy and want to be an awesome clinician. Gene Shirokobrod shared a helpful article in the DPT student Facebook group that I wish I had read before internships. The tips to pause, be grateful, and ask questions really improved my final internship.

Ultimately, I think I’m past Mount Stupid, but there’s still so much more to do and more to learn. I’ll keep this in mind as graduation approaches, and if you’re a fellow student, then I hope you will too.

Voice of the Patient with Gabriela Nunez

In the most recent episode of the Voice of the Patient podcast, Gabriela Nunez discusses her experience with two ACL reconstructions and the rehabilitation process following those surgeries.

Gabriela Nunez is a 3rd year DPT student at the University of Florida, who enjoys working with all ages and conditions ranging from athletic injuries to chronic pain. Gabriela is interested in the impact of psychology in the healing process, and hopes to see psychologically-informed practice become a standard aspect of our profession. Her goal is to work in a general outpatient clinic when she graduates to work with patients from all backgrounds.

You can contact Gabriela with comments or questions at gabimnunez[at]gmail[dot]com. She is also on Twitter @Gabriela_1725.

If you have a story to tell as a patient, provider, or both, then contact me on Twitter @zachrstearns.

By the way, we are excited to announce that this is the first episode of The Voice of The Patient since the beginning of our partnership with the Senior Rehab Project by Dustin Jones.

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*Find more helpful podcasts & blog posts at http://TheVoiceOfThePatient.org

*Check out the other podcasts in the Senior Rehab Project at http://SeniorRehabProject.com

The Voice of the Patient

The Voice of the Patient

I’m excited to join the team at The Voice of the Patient with Dave Reed. The Voice of the Patient has a mission that I believe in: “We’re working to change lives, that is, improve quality of life, by improving healthcare through not only hearing, but truly listening to the voice of the patient.”

In the midst of changes in the healthcare system, it’s far too easy to lose sight of person-centered care. I’m thrilled to join Dave Reed (follow him on Twitter) to give a greater voice to people rather than merely the profit-driven systems that dominate the conversation. On the the Voice of the Patient team, I will be interviewing people who are patients or providers (or both) who can aid the mission of truly listening to the voice of the patient. Check out this interview where Dave introduces me to the team.

If you are interested in sharing your story about the patient-provider relationship, then contact me on Twitter @zachrstearns or email me at hello@zachrstearns.com.

 

“Where there is despair, hope.”

“I never thought I would walk again.”

These words left me speechless. During an internship in an inpatient rehabilitation facility, I had been working with someone who recently underwent a transfemoral amputation. He was in a motor vehicle accident that nearly killed him. We worked through many periods of frustration and pain during our physical therapy sessions, finally seeing a reward after walking with a prosthetic, similar to this one.

As he walked, I focused on the quality of his gait, seeing that he needed some correction with his hip circumduction and excessive stance width. He didn’t care. Even as our patient took these steps, I felt as if I was reducing a life-changing moment to a slew of arbitrary jargon. He just walked without crutches for the first time since his life turned upside down. Not only that — I was also trying to pay attention to another patient and document both sessions despite how important these steps were to him. After our session, he hugged me and thanked me, and the room got really dusty really fast.

That was a special moment for me. It reminded me to fight the desensitization that comes with being a health professional. It’s tough to remember the importance of each moment when you’re also keeping track of other patients in the clinic, staying on top of the amount of time left in the session, and documenting efficiently throughout the day. This was one of the most important events in this person’s life, yet I was trying to juggle a handful of other tasks instead of offering my entire self to our patient. Perhaps I will be more mindful in the future as I continue to develop my clinical skills. On the other hand, perhaps I should be afraid of desensitization getting even worse with experience.

When I saw the relief and contentment on our patient’s face, I felt that every hour of studying and every tuition dollar was worth it. It is a profound privilege to be a therapist, and our patient reminded me of this in a huge way. Even though he probably had no idea, he taught me a simple, invaluable lesson: If I’m afraid of losing touch with people, then I should be more present with people. 

We should ask ourselves whether our systems in health care allow us to be truly present. It’s easy to blame problems on declining reimbursement, productivity demands, and documentation, but we need to challenge ourselves to do our best with what we have. If something about our health care system is truly interfering with our ability to deliver patient-centered care, however, then it’s time for a new system. What is more, we need to hold each other accountable and encourage one another to keep the patient at the center of our priorities.

Ultimately, this story was also a reminder of why I applied to physical therapy school in the first place. Of course I value the science behind physical medicine and rehabilitation, but I didn’t pursue the physical therapy profession because of science alone. If you are a health professional (or studying to become one), why did you choose your career? I chose this profession because of the opportunity to practice evidence-based medicine while building relationships with people. I chose a career in rehabilitation not just because of the evidence about pain, but because of the evidence about hope. “Hope is important,” as Thich Nhat Hanh writes, “because it can make the present moment less difficult to bear. If we believe that tomorrow will be better, we can bear a hardship today.”

The next time I see someone take their first steps with a prosthesis (or get out of bed without assistance, or return to the basketball court, or play with their grandchildren again), I’ll try to remember that I’m not just in the business of rehabilitation. I’m in the business of hope.

Are you?