Pot-Pourri

[Jo Bowyer]

It's decades since I supervised student osteopaths. The proceedure was that they took a case history and then brought it to the tutor for initial discussion before examining the patient. My student at the beginning of his fourth year was going through a dark night of the soul having come to the realisation that he wasn't going to be the saviour in a white tunic that he had been led to expect three years previously. His patient was a self employed carpenter who worked with his sons and had turned up at the sports clinic having tried everywhere else. He didn't do sport but had heard about us from a friend. He had a long history of recurrent eversion injuries to his ankle, had worn winkle picker shoes when they were the height of fashion in the '60s and was now hobbling around his workshop. The patient had been seen by an orthopaedic surgeon and had completed several courses of physiotherapy. Fusion of the joint had been suggested but the patient thought that "It was too final". We both went in to examine the gentleman who had high hopes that manipulation would get his stiff painful foot and ankle moving and cure his pain.

When we got back to the tutorial point, I asked the student what he intended to do with his patient. He said "Dunno, s'f*cked innit." I advised him not to write "s'f*cked innit" under diagnosis, mindful of the fact that I was going to have to countersign the case history sheet, but encouraged him to see it as a starting point. If we could get the patient to see the potential of fusion as a new beginning then something might be achieved.

We went back in and young Mr Potty-Mouth did a fine job of getting his patient on side.

I don't know what happened to the patient, but the student went on to build a successful family practice and was highly regarded by patients he sent to me in later years for opinion. They liked him because he "told it like it was" (Oh dear, I do hope not!) and if he couldn't help, tried to find someone who could and he wanted to know how they got on with whoever he sent them to.

Patients should not become dependent on their practitioners and they shouldn't feel discarded either.

[Johnny_Nada]

The word "context" is used a lot here.

What about the context the patient creates?

For example, I typically introduce myself as "Hi Mrs. Smith, my name is **** it's very nice to meet you"

What if the response is:

"Do you give pain pills here?"
"Oh, I hate that name"
"If you hurt me I'm going to punch you in the face"
"Your shoes are ugly"

(note: real responses by the way…)

[Mikal Solstad]

Wonderful point, Matt.

The appropriate context has to emerge from the therapist and the patient.

We aren't creating a context, we are co-creating it, hopefully in the direction we had wished.

[Jo Bowyer]

We aren't creating a context, we are co-creating it, hopefully in the direction we had wished.

If they come in with baggage co-created by themselves in collaboration with HCPs,CAM practitioners and purveyors of recreational exercise, I start by asking how that feels from their point of view, rather than attempting to take it off them and chuck it in the skip. I'm not proud of some of the guff I have come out with in the past. At some point during the first session I introduce the notion that what they have told me could be viewed through a different lens.

[nari]

Matt,

"Do you give pain pills here?"
"Oh, I hate that name"
"If you hurt me I'm going to punch you in the face"
"Your shoes are ugly"

Are you serious that these are actual statements by patients???
I find that rather scary. I have never received such negative criticism and demands from patients over 22 years. You guys must find your tolerance really stretched in such circumstances.

[Johnny_Nada]

Matt,
Are you serious that these are actual statements by patients???
I find that rather scary. I have never received such negative criticism and demands from patients over 22 years. You guys must find your tolerance really stretched in such circumstances.

nari,

All real statements, the first words out of the person's mouth, and all over the age of 30...

[Barrett Dorko]

Matt,

Maybe your shoes were ugly. Of course, there's fashion involved here so you never know. Well, I often don't know anyway.

Perhaps this person has often found that those who enter their room dangerous and willing to elicit a painful output, often without warning. I've heard, "She was really sweet. I thought she was going to kill me."

When walking into a patient's room the context is decided by both of you there. Looking and behaving in a surreal manner can make your visit memorable. It's remarkably significant.

Good luck.

[Johnny_Nada]

Barrett,

The shoes by today's standard were ugly. All comments were in fact from individuals that were raised and/or currently resided in violent, unhealthy homes and neighborhoods.

[Barrett Dorko]

Matt,

Isn't fashion hard to keep up with? I'm so old I still wonder about tattoos. My daughter, who I would do anything for, has four.

I've had patients who recently lived under bridges, were millionaires, were seemingly happy, seemingly sad, scared of me, glad to see me and a few other things. I dance around this and sometimes I fall. One day I won't rise.

What a life.

[Keith]

All comments were in fact from individuals that were raised and/or currently resided in violent, unhealthy homes and neighborhoods.

You raise a great point, Matt.

I remember wearing rose-colored glasses when thinking about treating people in their homes - you know, "Home is where the heart is." In the last 3+ years, though, I have realized that there are so (too) many families, homes, neighborhoods and communities that have ripped the hearts from people - there is no amount of context architecture that we can bring into the therapeutic encounter to offset these challenges. In these instances and under such circumstances, our already small odds of success are reduced (nearly) to zero.

Powerless,
Keith

[Jo Bowyer]

I like doing home visits as the locus of control is skewed in in favour of the patient.

[Keith]

I like doing home visits as the locus of control is skewed in in favour of the patient.

I often feel that way, Jo, but there are environments that I work in where it is abundantly clear that I could never steal from a patient a locus of control that they never had to begin with...and therapy isn't going to help them find it.

Respectfully,
Keith

[Jo Bowyer]

I remember those days. Unwashed patients in danger of setting fire to their frocks with cigarettes they lit off the stub of the last one. The ones I see now are comfortably off.

[nari]

Keith,

I admire your consistency in the face of verbal threats and total lack of understanding.

I could not do it, but I have practised only in the country's more elite(in terms of education, etc) so I would not know, really.

[Johnny_Nada]

nari,

the people keith and I describe are why I'm skeptical (and blatantly roll my eyes) when I listen to speakers talk about their methods for "treating" pain, return to work, etc.

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Rub, stretch, massage, scrape, poke their skin….funny. I've seen people actually roll their eyes and ask why a therapist is performing manual therapy. The replies from the therapist have ranged from non-sense to neuroscience. The patient stands up and says,

"I still hurt."

"Yes, but you are now aligned/I activated afferent receptors to promote/your straight leg raise is better/your shoulder range of motion increased by 6 degrees…."

"I still hurt"
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Promote mindfulness, relaxation, etc….funny…maybe for those whose family, home, shelter and/or neighborhood isn't a threat on a continual basis.
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Return to work is better for you….maybe when work actually pays the bills and puts food in your kids' mouth. What if it hurts and doesn't even provide a means to buy groceries and pay rent??? Who can blame them for not going back?
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I have yet to get anyone speaking at conferences, courses, classes etc provide me anything on working with this population other than "ummm, wow, I don't see people like that..that must be tough...do your best…."