No announcement yet.

Keith's Korner

This is a sticky topic.
  • Filter
  • Time
  • Show
Clear All
new posts

  • #31
    Originally posted by nari View Post
    Walden certainly had the knack of seeing things in different lights.
    Hi, Nari...I should have been more clear re: Walden.

    I was referencing Walden, authored by Henry David Thoreau.

    There are a series of passages that I found throughout its text that have inspired some new writings/thoughts. It is an interesting read.

    For instance the passage above had me thinking:

    I smirk and occasionally roll my eyes when I meet the therapist who informs me that they “treat the whole patient”. This implies that they have an special understanding or insight as to of how ‘the whole patient “works.”‘ Such a understanding, of course, is not available to them, but they have convinced themselves otherwise.

    . . . .

    Most therapists have 30-60 minutes at a patient’s initial evaluation to obtain knowledge of a limited number of variables that may impact a patient’s pain experience; they may have an adequate understanding of even fewer. Over the weeks that might follow, the therapist will often learn more about the patient; sometimes that knowledge helps them understand the patient more, sometimes less. It is with that limited knowledge and understanding that the therapist is to develop a plan of care to shepherd their patient toward a positive outcome.
    If we knew all the laws of Nature, we should need only one fact, or the description of one actual phenomenon, to infer all the particular results at that point…

    Patients with chronic pain are nomadic people, moving from one professional with a seemingly plausible explanation for their symptoms – each with their own approach to treatment – to another and another.

    Each clinician has a different formula or calculation that they make when they are completing as assessment; each clinician’s respective calculations are developed from a foundation of the literature and research that is (in an of itself) lacking. Unfortunately, a large percentage of clinicians who treat patients with chronic pain symptoms have no familiarity or understanding of that literature.

    …Now we know only a few laws, and our result is vitiated, not, of course, by any confusion or irregularity in Nature, but by our ignorance of essential elements in the calculation. Our notions of law and harmony are commonly confined to those instances which we detect; but the harmony which results from a far greater number of seemingly conflicting, but really concurring, laws, which we have not detected, is still more wonderful. The particular laws are as our points of view, as, to the traveller, a mountain outline varies with every step, and it has an infinite number of profiles, though absolutely but one form. Even when cleft or bored through it is not comprehended in its entireness.

    *quoted passages from Walden
    Blog: Keith's Korner
    Twitter: @18mmPT


    • #32
      Character Development

      In Awareness Through Movement, Moshe Feldenkrais proposed:

      The general tendency toward social improvement in our day has led directly to a disregard, rising to neglect, for the human material which society is built... Individuals, rightly or wrongly, tend to identify their self-images with their value to society... Despite the fact that the inherited differences between people are obvious, there are a few individuals who view themselves without reference to the value attributed them by society. like a man trying to force a square peg into a round hole, so the individual tries to smooth out his biological peculiarities by alienating himself from his inherent needs. He strains to fit himself into the round hole he now actively desires to fill, for if he fails in this, his value will be so diminished to his own eyes as to discourage further initiative...
      He continues:

      In all human activity, it is possible to isolate successive stages of development...At first these things (are) done "naturally," that is, in the same way that animals perform whatever is necessary in their lives...At the times and places where there (is) a new development, we always find a [second] special, individual stage. That is, certain persons found their own personal, special way of carrying out the activities that came naturally...When a certain process can be done any number of ways, somebody may appear who will see the importance in the process itself, apart from the way it is carried out by any individual. He will find something in common in individual performances and will define the process as such. In this, the third stage, the process is being carried out according to a specific method as the result of knowledge, and no longer naturally...

      ...We may observe, natural practices have gradually given way to acquired methods, to "professional" methods, and that society in general refuses to allow the individual the right to employ the natural method, forcing him instead to learn the accepted way before it will permit him to work...

      ... The power of the system is so great in their eyes that even the little they learned in their childhood of these things is gradually expunged from their self-image because they are occupied mainly with activities that they learned systematically and consciously. While such people are very useful to society, they lack spontaneity and their lives are difficult in areas outside their professional, learned field.

      We thus come back to the need to examine and improve our self-image so that we can live in accordance with our natural constitution and gifts and not in accordance with the self-image established by chance, more or less without our knowledge.
      Feldenkrais concludes:

      “The education provided by society operates in two directions at once. It suppresses every nonconformist tendency through penalties of withdrawal of support and simultaneously imbues the individual with values that force him to overcome and discard spontaneous desires... Every aspiration and spontaneous desire is subjected to stringent internal criticism lest they reveal the individual's organic nature... The only compensation that makes life durable despite these sacrifices is the satisfaction derived from society's recognition of the individual who achieves a definition of success.

      ...The satisfaction derived from the actions even when they are successful is not revitalizing organic satisfaction, but merely a superficial, external one.

      Very slowly, over the years, a man comes to convince himself that society's recognition of success should and does give him organic contentment...And, indeed, the private organic life and the gratification of needs deriving from strong organic drives are almost unimportant to the successful existence of the mask and its social value. The great majority of people live active and satisfactory enough lives behind their masks to enable them to stifle more or less painlessly any emptiness they may feel whenever they stop and listen to their heart.”
      . . . .

      I recently began to reading a chapter book to my son for the first time. My wife and I have read to him almost daily since he was 9 months old (if not earlier) and - up until now - he has "read along" looking at the illustrations. Now that he is getting older, I wanted to try to foster his visual imagination and I have begun reading a couple chapters per night to him from an un-illustrated text to try to encourage his imagination and curiosity while improving his attention and (hopefully) enhancing his desire to read about something other than NASCAR.

      The first book that I selected was Stuart Little. In case you are unfamiliar with the story - which I am reading for the first time and am only half-way through - Stuart is a mouse who (somehow) is the child of a human family. His mother, father and brother are all human. There are two other characters that live in the Little home, Margalo (a rescued bird) and Snowbell (a white Persian cat).

      The beginning of Chapter 10 begins:

      Snowbell [the cat] had several friends in the neighborhood...[including] a beautiful young Angora who had escaped from a cage in a pet shop on Third Avenue and had gone to live a free life of her own in the tool house of the small park near Stuart's home.

      One fine spring evening, Snowbell had been to call on the Angora in the park. He started home, late , and it was such a lovely night she said that she would walk along with him to keep him company. When they got to Mr. Little's house, the the two cats sat down...Snowbell began telling his friend about Margalo and Stuart [the bird and mouse that lived in the home with him].

      "Goodness," said the Angora cat, "you mean to say you live in the same house with a bird and a mouse and don't do anything about it?"

      "That's the situation," replied Snowbell. "But what can I do about it? Please remember that Stuart is a member of the family and the bird is a permanent guest, like myself."

      "Well," said Snowbell's friend, "all I can say is that you've got more self control than I have."

      "Doubtless," said Snowbell. "However, I sometimes think I've got too much self control for my own good. I've been terribly nervous and upset lately, and I think it's because I'm always holding myself in."

      "Look here," the Angora cat said to Snowbell, "I admit that a cat has a duty toward her own people, and that under the circumstances it would be wrong for you to eat the bird. But I'm not a member of your family and there's nothing to stop me from meeting her, is there?"

      "Nothing that I can think of offhand," said Snowbell.
      . . . .

      When I first began home care physical therapy, I was excited. I had seen the effects and impact that the outpatient therapy clinic had on my patients. I had come to realize that a clinic with 20 other patients, open doors, and a large gym is not the place to be one's authentic-self, especially when they are in pain. It was my impression that by visiting the patient in their own home I would have an opportunity to work with them in an environment where they would be able to truly thrive, in their most authentic or natural state. It would be their opportunity to be their inner-Angora, the creature who was able to escape the cage to live a free life of her own.

      Unfortunately, the patient in the home is often no different than the patient in the clinic. Worse yet, I have come to witness that the patient's least authentic self is often on display in the home and for their family. Perhaps the patient feels pressured to put on a show for loved ones to appear stronger than they might actually feel. In other instances, they are forced to remain stoic as they are constantly reminded of their inadequacy as they watch caregivers complete household tasks that were once their own responsibilities. Meanwhile, they remain home-bound and feel trapped, unable to move away from or escape a harsh reality that they never asked for or expected and have difficulty coping with. Regardless of their motives, my patients in the home care environment are exposed - and succumb - to the same societal pressures within the walls of their own residence as they do outside of it.

      What I failed to appreciate 20 months ago was that the culture does not stop at one's door step. Even in the confines and security of one's home, the culture does not stop impacting the self. Instead, the self has already (and will continue to be) impacted by a culture from which it cannot escape. Whether I see them in the home or in the clinic, that which was once natural to each patient has long since been stripped away from the person, leaving them hiding behind a poorly constructed mask meticulously sculpted by the society in which they live. They carry their mask always, in the home or out.

      Like Snowbell, they are working hard to keep themselves in and keep their masks up. Is it possible that they too are exercising too much self-control for their own good?
      Blog: Keith's Korner
      Twitter: @18mmPT


      • #33
        Friday Conversation


        I have recently decided to begin audio recording conversations with my kids...inspired by some the wonderful moments captured spontaneously by producers of some of my favorite podcasts (many of which I have linked to here in the past).

        Two weeks ago, while at breakfast at the local coffee house with AJ (in our customary seats with our usual orders), I recorded a conversation that I would not have soon forgotten, even if the recorder hadn't been running:

        Me: So, I have to tell you something buddy.

        AJ: What Daddy?

        Me: I was reading something on the computer last night that was posted to facebook by someone I know in Colorado, and I thought what he posted was a great idea. Do would like to hear what the gentleman's idea was?

        AJ: Sure.

        Well...what is one of the first things that I do when I get home from work?

        Give me a hug and kiss?

        Yes, I do that. But after that. What is it that I do after giving you a hug and kiss?

        You change your clothes?

        Yes...but before that I will often ask you a question about your day. I might ask you for instance, "How was your day?" or "What did you learn today?" Right?


        Well, Kyle (the gentleman in Colorado) posted something that recommended that should ask you what questions you asked that day.


        Because, we do our best learning when we ask questions. It is more important to ask difficult or challenging questions than it is to know a series of easy answers. Asking questions means that you want to understand something and understanding itself is a wonderful thing. So, I know if you ask a good question, you are doing your best work in school...even if you don't learn the answer.

        But I should always remember the answer, right Daddy?

        Sometimes there are no answers. That is what makes the question so important.

        But not as important as getting the answer right. Right?

        No, you are mistaken, buddy. Let me ask you this: what does Mommy do on the computer?


        What does Daddy do on the computer?


        Do you know why I am on SomaSimple?


        Because SomaSimple is filled with other people who appreciate the importance of asking questions and being humble enough to understand that they (and science) do not yet have the answers. And that is okay, so long as we understand that a good question is still worth asking.

        What don't they have the answers to?

        Not 'they', buddy...'we'. 'We', human beings, don't know all the answers yet. That is what makes science so exciting.

        What kind of questions?

        Well...for instance...we do not understand how consciousness happens.

        What is consciousness?

        Consciousness is what you feel, who you is everything that you experience. What part of your body do you think is responsible for making you 'feel'?

        The brain...

        Exactly, and your brain is filled with all of these little cells called neurons that talk to each other and communicate with electricity, just like the electricity in your house. You can flick a switch on the wall and what happens?

        The light turns on?

        Yep. So every time you see, taste, hear or experience anything, there are little electrical signals in the brain where cells are talking to each other. What we (science) don't understand is how those little signals become something we feel and experience - what we call consciousness.

        Well, wait a minute Daddy. Let me try to figure it out. (long pause of about 45 seconds) So...Daddy, I just thought that if we are like doing something, then we want to do something else, I think those little things in our brain - I think they send things into our body, because our brain is what technically sends stuff to help our body move. So, what I was thinking that those - if you wanted to do something else - those would tell your body to go somewhere else.

        [I think I know what he is trying to say] That is what happens to some extent, and we understand a lot of how that happens. We just aren't sure how those - how something electrical becomes something that you experience.

        Hmmm, let me think about that, because I can think of some good answers...I just have to think.

        Just so you know buddy, some of the smartest people in the world have read lots and lots of books and have done lots and lots of research and they still don't have the answers yet.

        Well, what if a kid got the answer?

        Then that would be an incredibly unlikely - but still possible - and awesome outcome.

        What does unlikely mean?

        In this instance, it is something that probably won't happen, because what you need to do to come up with a good answer, is you need to have a good understanding of the subject you are thinking about before you can get to the answer. So, for example, you need to understand how the nerves in the brain work first before you might understand how they might create that experience for you.

        Well...again, let me say my thing...


        Where was I?

        I honestly have no idea.

        Daddy...I think it is our heart that tells our brain - all those little electrical things in our brain - to do everything. That's what I think.

        Well, I believe that is what they used to think many years ago, because when the heart stops working, the brain stops working. People used to think that the source of all of our energy and thoughts might have come from the heart and now they understand that when the heart stops pumping, the blood stops going to the brain; then the brain can't work anymore because the blood is the fuel for the brain.

        But I think even if the heart is beating, it can still think that it is giving the thoughts to your brain. And that is what I think.

        Okay, you are thinking about this really well...and I am proud of you for that, but let me give you a little bit more information. What if I informed you that when someone's brain is damaged, but their heart keeps pumping...they still don't have thoughts or experiences the way that you or I would. So we think that it is more the brain that creates that experience of consciousness and feelings - beyond the heart itself. Because, if the heart itself created those experiences for you, you would still experience them even if the brain was damaged.

        Well, let me say this...I was thinking, maybe if you say what you just said again, then maybe I can come up with a better answer while I am listening to you. Can you please say it again, please?

        You shared with me that you thought that it might be possible that we feel and think more because of our heart than our brain. Then I shared with you that we have evidence that if the heart is working and the brain is not that people don't feel the same things anymore. So...

        But, if the heart...What if the brain was damaged and the heart was still pumping. You said that...

        The body is still alive, but you don't feel anything anymore.

        Well...let me say this. I was thinking, since you just said that about the heart and the brain, I was thinking that the heart and the brain work as a team to make those thoughts together, then they send those thoughts into your body and your body does what it needs to do do other things. Do you want to put that on SomaSimple and see if they think that it might be a good answer?

        I think that they would be very impressed with your answer, because you are 6-years-old and you do not have any formal training in neuroscience or physiology, but other people have tried similar answers and approaches to try to find the answer, but it has proven to be untrue. But...if it is something that interests you, when you get older it can be something that you learn about or try to study. Do you know what people are called who study the brain and how it works?



        Hmmmm. That's a funny name.

        Well, you know what a scientist is, and 'neuro-' deals with neurons, the little electrical cells in your brain and throughout your entire body too. They are the messengers that send...

        Stop...Stop...Stop. I just came up with a good answer. Since they are in your whole body, maybe the brain and the spinal cord and the heart - I was thinking - all of those electrical cells in your body must all work together - plus the heart - to make everything. You know your thoughts...

        You are right. It is called embodied cognition. It means that your thoughts and experiences cannot be separated from your body. Not just your brain. Not just your heart. Everything. That is a term that I still don't fully appreciate or understand, but that I was first introduced to on SomaSimple.

        Did anyone ever post that on there, because that could be a pretty good answer to a question.

        You are is definitely part of the answer. But, again, what we don't understand is - ugh, I am trying to think of a good example for you.

        Just put it in the same words that you therapists express it and I'll try to give you the other part of the answer.

        Well, often we do better explaining things through metaphor, which are stories or examples of things that are similar. So, for instance, the electrical signals in your brain are (at a small level) kinda like lightning. But those electrical signals not only help your muscles move...they also give you your experience. They help you see. They help you hear...

        Stop. I think the whole body, plus the heart...

        Don't forget the heart is part of the body.

        Okay...I think they all work together to make you see, hear, move, chew, even grow teeth. So...that might be another half of the answer. Do you think that could be another part of the answer?

        I think so...but that still doesn't explain how a bolt of lightning can make a movie happen.

        What do you mean 'a movie'?

        When you see with your eyes, you see the whole coffee house, all the people. You see the blue walls and all the Christmas ornaments and decorations. There is a movie happening right in front of you..

        Yeah, yeah.

        That movie is happening because you have all of these little electrical signals happening in your brain. So on a much larger scale, if a flash of lightning happened and a movie suddenly appeared in the sky, we wouldn't know how to explain that, but that is what happens every moment that we are awake and every moment that we are dreaming. Those little lightning flashes inside your brain are creating for you an experience that we just don't understand yet.

        Alright, so...wait...well, maybe you could just give SomaSimple part of the answer. Maybe they would think that that could be half of the answer.

        And maybe they could build on it?


        That, my friend, is science. Science is when one person finds a small piece of answer and another person finds a small piece of an answer and they - over time, years and lifetimes - people will take all of those little answers or puzzle pieces and put them together to develop a greater understanding of the whole picture, not just little pieces of a puzzle anymore. you want to say that on SomaSimple? Because I think that is a really good answer for part of the question.

        You know what? I would love to share it with them.

        Cool. I would be can do that if you want.
        Last edited by Keith; 20-12-2013, 04:45 AM.
        Blog: Keith's Korner
        Twitter: @18mmPT


        • #34

          Emergence is a really interesting phenomenon. Emergence is when the system does things on the systems scale that you would not be able to predict from the components and how they interact. Let’s take the human brain: it is a complex system. The entities are neurons (nerve cells). They’re connected to each other. They send signals to each other. They are all very simple, and in fact you can write down mathematical equations which are quite good representations of what neurons do. But, now you connect a huge lot of them together and out of this comes things like consciousness – we are actually aware of ourselves and our surroundings in this rather big, big way. There is nothing in the structure of a neuron that says it’s got to do that, that (in a sense) the neurons don’t know about that; yet cognitive scientists would say that this is not some extra/external thing that is wonderfully being imposed by some[thing] supernatural…You can understand little parts of the brain, but even that is quite difficult… All of the evidence is that, somehow, what all of the wonderful things that the brain does – like language, like vision, hearing, taste, our senses, our movement – all of this happens by neurons exchanging electrical and chemical signals along the network. The network changes as we learn. The network changes as we grow from babies to adults… What it (the brain) does may not be as complex in itself as all of the underlying details. When I am talking to you, we could describe the whole conversation in ordinary language very, very clearly. If I tried to find out and write down what all of the nerve cells in our brains were doing when that happened it would be impossible to describe.

          Once that emergent is in place, there is an additional dynamic. The emergent has 2 effects, it both constrains certain behaviors of the interacting entities (because there are existing systems in place) while, at the same time) it opens up new possibilities. And that makes it a very, very dynamic process. It is not only a bottom-up process, it is also a top-down process and the whole thing is changing very dynamically the whole time.
          Recently on Facebook, I posted (on 2 occasions) a link to a podcast from In Out Time with Melvyn Bragg on the subject of complexity. In a related post, I wrote, “Physical Therapists continue to fail to addresses patient’s complaints of pain because we have – and continue to – insist on creating complicated explanations and models that are necessarily insufficient to understand our patients complaints. When will we learn? The problem is one of complexity, not complicatedness.”

          A few years ago, I would have viewed such a remark to be an exercise in semantics. Today, I have a better understanding of how the words we use necessarily shape how we think and how we interact with our patients. As a result, I would like to take this opportunity to review some of the important ideas that I took away from this particular podcast and how they may relate to physical therapy practice – especially when providing care to patients with painful problems.

          So, how is the idea of complexity related to physical therapy?

          Complexity is a point of view about systems in which large numbers of agents or entities which interacting according to fairly specific rules. The idea is to set up a mathematical model to represent that kind of system in a very accurate way.
          Sound familiar? How about that part of us that is 25,000 cm² in size and comprised of 100 Billion neurons in the brain alone, each with 1000 to 10,000 synapses. It is that part of us that – if we lined it up each piece from end to end – would be approximately 600 miles long.

          Yes, I am referring to our nervous system, arguably the most complex thing that we, as humans, have ever studied (or ever will). Thus, to be clear, all of our conscious experiences and everything that makes us who we are is necessarily derived from the most complex of complex systems. If you are a clinician working with patients in any field of medicine, you must appreciate the complexity of the system with which you are interacting and embrace the idea that you indirectly become a part of it.

          Of course, complexity goes beyond neuroscience. The science and study of complexity applies to a variety of subjects from how birds flock, to metropolitan design, to economies, to weather forecasting and medical management. For instance:

          From a more practical point of view, [an understanding of complex systems] would allow us to be able to do things like manage an epidemic better. This is a major problem. You know that there is a disease coming…but what strategies should you use as a government to try to contain the outbreak better? So if you have mathematical models that are good enough, you can try strategies out on the models. You can do experiments on the models which you cannot do on the real world and you can maybe learn how to deal with these problems.
          So, scientists are using complex systems models in an effort to try to understand a variety of phenomena in our world. But how does this apply to physical therapy, specifically?

          Reframing The Therapeutic Encounter

          Historically, physical therapy has been a field of linear thinking: an individual seeks care for a painful problem; the physical therapist’s responsibility is to provide the patient with an assessment including a variety of tests and measures that are historically used to find a specific offending structure or underlying problem that should be predictably managed with a specific routine or plan to alleviate the patient of their primary complaint. The patient presents with ‘B’, the therapist provides ‘C’ and the patient is supposed to be rehabilitated back to ‘A’ again (more on this later).

          Of course, the patient does not always get back to ‘A’, so the therapist continues to pursue a variety of reductionist and linear clinical models in an effort to try to find the one that will ‘work’ with the patient in question. Sometimes the therapist ‘gets it right’ on the first try, often they don’t. Perhaps, it is time for the entire field of physical therapy to approach things differently.

          Complex systems science is a new way of thinking. It contrasts with a 19th century view of science which is a lot more mechanical and deterministic. In complex systems, the dynamics of the system generally emerges from the interaction of the parts and their agents. And that is not necessarily predictable in the way that traditional science thinks that it should be. Complex systems science is very much computer enabled, because we have to compute the interactions of the agents and find out the way the system dynamics are evolving… Our outlook has changed with regards to what ‘prediction’ means. In the 1960s, the meteorologist Lorenz discovered that there are systems that are sensitive to initial conditions so that a slight change in the conditions at one time can mean the system can diverge greatly at another time. So, our expectations of what we can predict in physical systems has changed a lot in that time.
          Let’s state this clearly: only with computer models, running a variety of simulations with an ever-expanding number of initial conditions, could a therapist possibly discover the possible outcomes of their interactions with their patients, be they the environment in which the patient receives their care, how the therapist is dressed, the words/tone that are used in communicating with the patient, the location where the therapist places their hands and how firmly (or softly) they place them, or the expectations that the patient or therapist may have at the outset of a clinical encounter. If at any point in their career, a physical therapist feels that they have seen enough patients to recognize patterns of how they may necessarily be impacting an individual’s experience (B + C → A), they are fooling themselves.

          I am not saying that they are poor clinicians, I am only pointing out that the science is informing us that their interactions with their patient’s do not yield results as predictably as one might often think that they do, and even if they are fruitful, they are unlikely to be beneficial in a way supported by conventionally linear thinking. The models that therapists use for thinking need to change. They need to embrace the science of complexity.

          Butterfly Effects: Missing Flights, Wild Turkey and 4th ribs

          [In a complex system,] if a butterfly flaps its wings, you could potentially have a storm form somewhere that wouldn’t form somewhere else… Like many things in systems science, metaphors are used and misused. [And while the butterfly effect metaphor is often misused], it is true that changing initial conditions would change the outcome…For example, if you wake up 5 min. late, you might miss the bus. If you miss the bus you might miss another connection and you might miss your flight. So something very small can end up in a very big change.
          It would seem that, in many instances, therapists benefit from the existence of the butterfly effect, but neither appreciate or understand it. Even still, in many instances, they rely on it. Recently, I heard a podcast with a researcher/clinician who argued that distal lower extremity pain could be understandably effected by the application of manual forces to the 4th rib in the thorax, correcting for less than optimal alignment of the thoracic cage. The individual was able to – biomechanically – account for how this might happen and it sounded incredibly impressive. As a matter of fact, it was humbling to be reminded of how little one knows; such was the case for me as she so easily and quickly rationalized through the anatomy/kinesiology on her way down the chain from thorax to foot. Of course, the clinician admitted, 2 patients may present with the same complaint in the lower leg and the same positive finding (with palpation) in the thorax, but only one may be a ‘responder’. The pain may persist in one individual, while it is reduced or abolished in the other.

          How can that be so? If the biomechanical reasoning is so sound – and it is – how is it that the pain persists?

          There are things that are – for all practical purposes – unpredictable…As the system’s behavior diverges, you get a kind of horizon beyond which prediction doesn’t make any sense….We need to make a very clear distinction between complex and complicated, because we often confuse the one for the other. Complicated is very much a machine-type system. In a complicated system, we can design, we can predict its behavior, and we can control its behavior. We can do none of these things with a complex system…
          Let’s look back to the example of the bus from the podcast: What if, on the same day that you woke up 5 minutes late, there was also an accident on a nearby highway, which backed up traffic down the on-ramp 3 blocks from your bus-stop. Granted, you had to wait for the next bus, which was later in the commute, so there was heavier traffic, but did you realize that the traffic was actually heavier and slower more than is typical, because of the accident? Did you realize that the accident had involved a tractor trailer whose contents were spilled all over the highway and took an inordinately long time to clean up? Did you know that this accident (and the traffic delays as a result) was so bad that you would have been late for your flight even if you had woken on time? Of course, you don’t know any of that listening to your iPod instead of the traffic report on local radio. While you are jamming out to Pearl Jam angrily blaming last night’s extra shot of Wild Turkey for your tardiness, you are unaware that a truck driver spilled coffee on his lap 5 miles from your home and you are going to miss your flight as a result.

          When entities interact, they create complex behavior, and they start connecting with each other. It is not only a matter of connection, it is also a matter of interdependence that then arises from that connectivity…A lot of complex systems you can actually represent the connectivity as a kind of network (paraphrase) drawing all the entities and all of the entities that they make contact with along that network. The structure of the network effects very strongly the speed of transmission of impulses or signals along the network and where they spread to. If highly connected, one entity can impact a large number of other entities…We often assume that connectivity is the same over time, but it is not. The quality and intensity of connectivity varies all the time and we need to understand that connectivity is not the same over time. It does vary.
          What if you knew a the coffee-shop hostess had mistakenly not sealed the truck driver’s coffee cup completely? What if you knew that it was her first day working with a cast on her non-dominant left hand that she broke over 2 days ago when her 60-pound mongrel unexpectedly chased a stray cat while on an otherwise pleasant walk, knocking her to the ground?

          How could you imagine that a cat garnering the attention of a dog (45 miles away) would eventually lead to you missing your flight 48 hours later? You couldn’t, and that is the point.

          Waking up 5 minutes late is the positive finding at the 4th rib. Sure, waking up on time might help. So too might placing your hands on their thorax. But even if there is no accident, you arrive to the bus on time, the woman doesn’t break her wrist, the driver doesn’t spill his coffee, there isn’t an accident on a highway, the bus driver gets you to your connection on time and that bus driver gets you to the airport on schedule…do you get to take credit for all of that, because you had the resolve to get up on time despite that ill-advised shot of Wild Turkey? No, you get to breathe a sigh of relief every morning when things just happen to work in your favor. Likewise, a physical therapist should breathe a sigh of relief when their patients improve, not pat themselves on the back when the patient is “rehabilitated”.

          What “Rehab”?

          Why the “scare quotes” around “rehab”? According to Merriam Webster, rehabilitation is most often defined as, “to bring (someone or something) back to a normal, healthy condition.” This would hold true in the traditional model of physical therapy care that I referenced earlier: B + C → A. It is clear that, on one hand, there are far too many variables to make this an accurate account, but I want to explore the notion of physical therapy, even in a complex system, getting a patient ‘back to where they were’ before their injury.

          Very often in these networks, you’ve got all types of feedback loops and they interact, so there is intense complexity to these networks and the loops; that is one of the reasons why systems that are (locally) easy to understand become very complicated when you look across an entire network. We also need to differentiate between positive feedback and negative feedback. In positive feedback, there may be multiple equilibria. We need to distinguish that from negative feedback, which closes the gap between the actual and the desired; that has a single equilibrium point.
          The initial primary complaint of a patient is very rarely of a specific dysfunction (i.e. something is wrong with my L3-L4 facet). No, their primary complaint is more often related to their general dysfunction. They walk in and say, “My back hurts.” For decades, traditional care involved the therapist using a complicated reasoning model to discover an underlying dysfunction that would predictably respond to intervention, bringing the offending structure back into equilibrium. Again, sometimes it worked, often it did not. This, is because even if the therapist was able to restore health to a tissue or optimal movement to the perceived offending structure, they were working from a false premise.

          Often, in complex systems, we assume an equilibrium point and we make wrong assumptions. We assume that (as in a simple mechanistic system, with a single equilibrium point) that if we apply the right amount of correction at the right time, it will actually go back to its equilibrium…We cannot do that with things that are complex.
          While the bones, joints, muscles, ligaments, fascia (etc) are all parts of an admittedly complicated mechanical system, they are but pieces of a marionette**. It is not the marionette that feels, senses, emotes and motor plans, but instead the puppeteer. It is the puppeteer’s own complex nervous system that brings the puppet to life. It is the nervous system of the puppeteer that brings about the marionette’s expression, its movement. Most importantly, it is always the puppeteer – never the marionette – that feels pain. All that the puppeteer is, with all of his complexity – all of his experiences since he was born, his expectations, his fears, his motivations, his desires – is screaming in pain behind the curtain while the therapist provides treatment to a puppet on a stage.

          Meanwhile, the therapist is trying to “get the patient back” to how they were before – to bring the patient’s experience back into equilibrium. This, however, can never be the case.

          You cannot go back to what existed in the past. There is no reestablishing a position, because the system – by exploring new alternatives and evolving – will attain a different state. One equilibrium shifts, however, there are multiple equilibria at one time, not a single one. That is the key thing here. Or there may be no equilibrium at all; the system might be in a state of constant change. In traditional science, you have a formula. For example, if you fire a cannon ball, you can predict exactly where it is going to land in when it is going to land. In most of the systems we call complex, we can’t do that with any degree of certainty.
          While the therapist has extensive knowledge of biomechanics and is often indispensable in the helping the patient regain once lost mobility and strength, the primary job of the physical therapist is to guide a nervous system in such a way that it is able to discover how to move comfortably and efficiently once again, using neural circuitry in a way that it has never done before, reshaping the patients neural pathways, creating new neurotags. What we do as therapists is more wonderful than we give ourselves credit for…when done right, it is a beautiful thing – even though we don’t have control.

          Where do we go from here?

          I am not necessarily advocating for therapists to necessarily change what they do in the clinic, but I am insisting that they approach each encounter with the awe, humility and respect that a complex system should engender, appreciating that their job is not to get a patient “back” to where they once were, but to being them forward to where they want to be. If the therapist is able to maintain that perspective in each encounter – with every patient – they can come to the realization that they do not rehabilitate so much as the educate.

          We must understand that what therapists say and do with their patients at any moment not only impacts them today, but also tomorrow. Therapists create explanations and expectations, nocebo and placebo; they create a context through which a patient experiences each and every pain for the rest of their life. It is of utmost importance that the physical therapist appreciate that responsibility.

          [It must be made clear that (even when computer models are utilized)] they are unable to predict the results of the system once and get the answer. What happens is you have to run the system many times, because most of these systems are sensitive to initial conditions. So through the computer simulation you get an understanding of the space of possibilities. But initial conditions have their own dynamic, [called] path dependence, which is [to say] what happens in a system depends on his history.
          Every encounter, everything that a physical therapist says and does must be presented to a patient with the understanding that the therapist is introducing a new initial condition to a complex system. Every time a therapist provides the patient with a complicated explanation for an output from a complex system, they fall woefully short of providing appropriate care for their patient. They conflate correlation for causation. They reinforce their own cognitive biases and poor pattern recognition while instilling those some biases in their patients. They change the foundation on which the patient builds the rest of their life, and the lives of their patient’s friends, families and acquaintances. The responsibility of the physical therapist is not only to get their patient better, but to prepare that individual, with their complex nervous system for the rest of their life. The patient should walk away from a clinical encounter not with the notion that the therapist ‘fixed’ them, but that the therapist helped them fix his or her-self.

          Complexity is ordinary, it is a different way of thinking into a science that is quite young, so we don’t have answers for everything and it wouldn’t be just if we said that we did…If we understand the characteristics of complex systems, we can work with those characteristics. If we don’t understand them, we can actually inadvertently block them and go against what we want to achieve.
          A Closing Note to the Clinician:

          I get it. We went to school to look at a patient as a complicated system. We were taught to find something that is wrong and to fix/change it; the patient will feel better as a result. But we have to know better now. It is time to stop thinking about the patient as a complicated machine some of the time and a complex system – with variables beyond our control – only when it is convenient. It is time to move the profession forward.

          Some patient’s pain complaints will improve. Sometimes it will be (in part) due to your intervention, other times it is an illusion (in which case, get over yourself, they were going to get better anyway). And here is another newsflash: even when the patient does get better, it is unlikely to be for the reason why you think they did.

          How is it that when it is the patient’s fault, we blame a complex system beyond our control (they won’t stop smoking, they are non-compliant, they have ‘psycho-social issues’). How is it that at the same time we place accountability on complexity in those situations where we fail, we take take credit for the output of the same system when we think we succeed? It is sheer hubris.

          If you want to continue to seek the one complicated approach that is better than all the others, I won’t discourage you from doing so. If, while using your favorite approach, you see a bad posture, fascial restrictions. an AIC, a less-than-optimal thoracic ring or a crossed pelvis, you are free to use whatever approach you see fit to try to provide your patient with novel stimuli to alter a neurotag. You are working with a complex system, after all, and you very well may have a profoundly positive impact on that patient – I hope that you do.

          But, in the event that you are successful, keep your clinical reasoning to yourself, unless you also want to include in your humble explanation to the patient all of the non-specific and complex variables that also intervened, uncertainty and doubt included. Do not send them home thinking that you fixed something that was necessarily wrong, and THAT is why they feel better. Don’t you dare. You know better. You know that working with a complex system necessarily prevents that from being the case. You know that you have a responsibility to provide that patient’s nervous system with a scientifically valid and appropriate initial condition to live the rest of their life with, one with a defensible understanding of why they feel as good as they do.

          In the end, we are residential electricians. Don’t overcharge the customer while telling them that you are responsible for the power grid.

          *all quoted materials are from the Complexity podcast

          **I need to attribute this metaphor to Diane Jacobs, PT. I thought I had come up with it by myself, but after some research, I discovered I had read something similar last year. I felt as if I had slept on Ziggy bedsheets (Seinfeld reference)
          Blog: Keith's Korner
          Twitter: @18mmPT


          • #35
            'In Pursuit of Understanding' - this is excellent!
            Rob Willcott Physiotherapist


            • #36

              Great stuff. Should be required reading for everyone.



              • #37
                This is brilliant Keith. Today when I read this:

                Let's face it - private practice is a BUSINESS. In the end, there are bills to pay. There really isn't much time or space for idealism - for what should be or could be... the reality is that PPPT is the ultimate litmus test of what physical therapy is actually worth in the marketplace. When the blanket brand of physical therapy yields the images above... the brand is (in more than one dimension) failed for the private practice segment. Sure, there may be plenty of momentum in work-comp, large health systems, and/or inpatient care - however, this means very little to the private practitioner who has financially attached their homes to their business.
                e. The marketing arm in this equation is to make well-known the SERVICES available; not the body of knowledge which surrounds the expert - for the consumer doesn't care about what you know.
                The same goes for physical therapy. FMS/SFMA brands for a systematized analysis of movement patterns to tease out and ultimately correct painful dysfunction. MDT brands for a uniform (again, UNITY!) method to address directional pain - primarily circulating around the spine. The newly trademarked (very smart business move, by the way) osteopractic approach focuses care on spinal manipulation and dry needling. These are services - and - the service is the brand. This service is the signature moment. And, it is from this signature moment that an entire industry can launch rebranding, brand expansion, legislative moves, and increase public goodwill.
                I feel like I want to pull my hair out. But your post is an absolute rejection that we as therapists don't have to succumb to such garbage. You, are what our profession needs more of, critical and thoughtful reflection not this pandering and marketing that overwhelms PPPT.

                Thanks for being you, Keith, keep it up it is inspiring.
                Body is imbued with mind, and mind is embodied.


                • #38
                  One very interesting reflection I am having is the concept of invariance. Despite the multitude of factors which may delay my arrival at work each day, I find a way to always be on time for the first patient of the day.

                  It is a delicate dance between complexity and the dynamic equilibrium that defines the invariant conditions that we perceive and act on around us.

                  Body is imbued with mind, and mind is embodied.


                  • #39
                    Originally posted by Milehigh View Post
                    One very interesting reflection I am having is the concept of invariance. Despite the multitude of factors which may delay my arrival at work each day, I find a way to always be on time for the first patient of the day.
                    As do I; my wife on the other hand is another story altogether.

                    I appreciate that my commute may not always go the way that I want it to, so I always plan to leave for work 15-20 mins earlier than I would typically need. If the cat unexpectedly vomits on my kid's toys, I am still on time after a thorough clean-up. If the car doesn't start, I have time to jump-start it. Traffic...not a problem, I can find a way to drive around it.

                    Providing the patient with a complicated explanation for their painful experience and the care we provide is like leaving the house with no time to spare. Sure, we might get to work on time - but there are times when we will be woefully late. The patient, on the other hand, has been waiting long enough for genuine care.

                    I agree...our patients deserve better.

                    Blog: Keith's Korner
                    Twitter: @18mmPT


                    • #40
                      Originally posted by Milehigh View Post
                      Thanks for bringing me back down to earth ***...the quoted passages above are from the same gentleman who has titled himself the 'Primary Spine Physiotherapist' of a major hospital in the Greater San Diego Area (cool, huh?), has trademarked one of his approaches, still uses the HNP model in making recommendations for LBP prevention and states, "It is important for us to train our bodies to recognize and adopt ideal postures as unconscious habit. Good posture promotes good health, bad posture leads to injury and/or illness."

                      In the posting you referenced above, he quotes Tecumseh:

                      "A single twig breaks, but the bundle of twigs is strong."
                      If this is what is takes to succeed in PPPT, I will risk it as a single twig.

                      I may never live in palace, but I would rather an honest life humbly than naively mismanage patients in pain for my own profit.


                      ***There has been such a warm reception for the Complexity posting (even outside of SS)...I forgot things aren't necessarily changing as we think they should
                      Last edited by Keith; 21-01-2014, 02:31 AM.
                      Blog: Keith's Korner
                      Twitter: @18mmPT


                      • #41
                        The real-world is lonely

                        For those of you here who are not FB friends, I thought I would share this here as well:

                        I am spoiled in the world I have created - working in home care alone, interacting with brilliant and motivated minds online. But every once in a while, I come across a 'just doin' my job', 9-5er and get frustrated. For instance -

                        Yesterday, in conversation with a PT, I mistakenly made mention that after 60+ minutes of basketball (my first time playing in nearly a decade, while already out of shape), I had soreness in my posterior thighs. I was asked if I had stretched after. I said that I hadn't and was prompty chastised for allowing lactic acid to build up in my muscles and not stretching to get rid of it. This begged a few questions, of course....

                        "Really? Is that what you tell people? You know that there is considerable evidence that lactic acid is not a contributor to DOMS, right?"

                        "Even if it was lactic acid in the muscles, how do you propose that passively lengthening tissue and potentially narrowing blood vessels improves circulation?"

                        This woman, a PT grad in 2001 and a spinning instructor at a variety of local gyms, wouldn't cave, though. She replied, "Then how do you explain that I don't have muscle soreness after activity when I stretch?" I replied that (1) she is in better shape and she is physiologically capable of placing the load on her self and (2) the placebo effect. I was then informed that I was wrong, because when she doesn't stretch, she can feel the difference.

                        "Well, the most plausible explanation is the nocebo effect," I replied. Of course, that can't be the case (in her mind) because she isn't conscously thinking about not stretching or the potential for discomfort - 'it just happens'.

                        I asked her if she thinks that that the conscious-mind is the part of her that is really in control - "Can you control the thoughts that come to your mind and when?" "How do you account for a song that gets stuck in your head and you can't get it out?" "Isn't it reasonable to think that if you have an unconsious expectation, that it would wield control over your conscious experience?"

                        The conversation could have continued further, but I had to stop trying when she said, "I hear what you are saying but I just believe that there must be something to it if it works for me like it does and..."


                        I wish ALL PTs were like driven internet-active PTs/clinicians/practioners).

                        Anyways - thanks for being here, friends. I still have A LOT to learn, but I am thankful for this little Oasis that we share.
                        Blog: Keith's Korner
                        Twitter: @18mmPT


                        • #42
                          So much of the wonderful stuff here was written in January of this year. I even "liked" some of it then.

                          Tomorrow's new Sunday Series, Sand Pile, will focus on chaos theory and it will refer to this, of course.

                          I have to reread it though. I have forgotten what was said.
                          Barrett L. Dorko


                          • #43
                            Some of the best posts I have read on SS.

                            Thanks, Keith.


                            • #44
                              I just read your blog post titled Bea's Bunker. Fabulous piece. It seems so simple, but soo complex when you get it. All of our training, with it's practice acts, it's wars over contexts of care (despite a lack of evidence), creates walls between us and the patients. What providers don't realize is that when you fill your mind with internal dialogue of joints, meridian's supernatural powers, myofascial patterns of restriction you push out the stuff that really matters. You are unable to reach the patient in a way that actually understands their life and their struggles.

                              You reasoned through all this contextual mess that swirls around you in the modern health care environent. Where patients are plugged into providers given the 'treatment' and everyone just crosses their fingers and hopes the patient feels better. Instead of doing that you went after Bea. You rolled up your sleeves and got into her life. Probably more so than any other provider has done in the past. She got so much attention from you that when she goes anywhere else in the future she is going to miss how much attention you gave her--she will remember.

                              I think you clearly articulated what it means to clinically reason about pain in the modern way. Yes you are informed by the neuroscience but that is not what you are affecting. You are affecting the person in front of you.

                              A few reflections of my own. After people have gone through changed roles, where they have cared for a loved one up till their death I sort of envision sometime of war or sports analogy. Where the individual for months/years has been neglecting every little bit of nocioception--some of this neglect is actual supression. Of a similar type that a running back does to run through a wall of defenders. Except the end point is not a touch down but loss. In the very act of enduring these periods the patient must not and cannot feel the pain of their body--for that pain would be the culmination of and lead to a host of behaviors that would be opposed to the act of caring for another.

                              After the loss, the person is left without a life defining role, the support of a loved one, and a host of sensations and feelings they have been neglecting/suppressing. These things come roaring to the forefront of their consciousness. The uncertainty that accompanies pain with the lack of support in her own life led her to your door. Rather than blamed, you accepted. Rather than poke and prodded you listened and engaged. This is and needs to be the future of care. It is mess, unsexy and ultimately probably won't have better outcomes than standard forms of therapy. However it will cost less and people will feel better because of it.

                              Thank you for having the space mentally, physically and temporally to fit this patient into your life. Your as close to a master clinician as anyone I have ever met. Keep it up.


                              Sent from my iPad using Tapatalk HD
                              Last edited by Milehigh; 14-07-2014, 05:38 AM.
                              Body is imbued with mind, and mind is embodied.


                              • #45
                                Analogy for Nociception and Pain

                                I came up with this explanation of nociception and pain early today (aimed at my father); thought I would post it here:

                                What you need to understand, Dad, is that nociception - the signals from those nerve endings in your hip are just dummy lights, nothing more.

                                Remember my '87 Caravelle that had the temperature light that would always turn on and we kept replacing the thermostat until we figured out the computer was broken, then we just kept driving it because it was cheaper not to get it fixed? Sure the light came on, but we were able to make an assessment and determine if that signal had any value - in that instance, we quickly learned that it had no value and I learned to simply ignore it.

                                Or how about when you are driving around town in one of your vehicles and the 'low fuel' light turns on? Whether you decide to fill up now or later depends on the vehicle you are driving, how far you need to go and what neighborhood you are in. If you are driving the pick-up, you know that you can not drive as far as in the Elantra before you run out of fuel, so the vehicle you drive - to some extent - changes the meaning of the light. If you are only a few minutes from the house, you might be able to run a few errands over the next couple of days before filling up. Meanwhile, if you are on the south-side and would prefer to avoid the risk of getting shot when you step out of the vehicle, you would probably keep driving until you are in a safer neighborhood. Even still, there are times when the light will turn on and off , simply by parking the car facing up or downhill - with the actual fuel in the tank changing.

                                The point is, nociception - those signals that originate in your hip (for example) and arrive at your brain after traveling through the spinal cord - are only dummy lights to the unconscious mind. The brain still gets to decide what it wants to do with the information once it gets there.
                                Last edited by Keith; 20-09-2014, 12:51 AM.
                                Blog: Keith's Korner
                                Twitter: @18mmPT