Saturday, January 25, 2014

Laughter In The Clinic

“If we couldn't laugh we would all go insane.”
Robert Frost

One of the things I do lately is looking back. If we're talking about racing, then literally looking back is usually a fruitless endeavor as there's mostly nobody back there. But, when you're out on a long solo run in the woods, you have a long time (some of us longer than others) to reflect, and two of the things that involve most of my time these days are my work (Physical Therapy) and running. I've been a PT for almost 43 years and ran my first marathon over 34 years ago, so these paths parallel each other fairly closely and sometimes actually cross. As I was bounding down a switchbacking single-track this morning, I was trying to come up with the things I hear over and over again in the clinic, and seeing that I am coming up blank for a running theme for this post, I thought I would show you what I encounter daily trying to extract information from patients. Now, you have to understand that some of these patients are runners, and generally they have a stoic "No bone is showing so I can run on it" attitude, but the typical patient is generally of the "I think I overdid my home exercises" approach, when what they did was lift their leg 15 times instead of 10!

I work in an outpatient clinic, and getting folks to do their exercises is sometimes near impossible, but there is a repeatable theme they come up with. It doesn't matter if your a runner, a Physical Therapist, or a typical off-the-street patient, you will never do home exercises as much as told to. They're boring, they're repetitive, and you won't see instant gratification. Don't won't do, you won't!!

When I first see a patient, I do  a subjective and objective evaluation. The subjective is just asking them about their condition and the objective is all the measurements. Nothing funny about the objective, but the subjective is a trip sometimes:

ME: "How much pain do you have?"

PATIENT: "Hard to say. I have a high pain tolerance.”. Ha! They'll tell you how they gave childbirth in the back of a car, had teeth pulled without Novocaine, or eat Jalapeno peppers like candy. But, just try to move the involved arm or leg and they are squirming around like they're on fire. What they usually show is an extremely poor tolerance of pain...or even a poor tolerance to slight discomfort. It is classic.

RUNNER: "I don't know. I just ignore it.". They figure if they can "run" at all, it is safe, or necessary to do so. Had a runner tell me once "It's not a sharp 5k pain, it's more like a constant marathon pain". Actually, that was a pretty good description. 

ME: "Describe your pain"

PATIENT:  "I have no pain, it’s just sore.”. This is another classic. No pain, huh? Then I ask them, "try to grade your pain on a scale of 0 to 10 with 10 being the most". You'd be surprised how many people are walking around joking and laughing with 10/10 pain!! I thought you said you had no pain! I try to tell them that 10 is Emergency Room pain..."I told you I have a high tolerance of pain". Huh? If you're rating it a 10/10, then you don't have a very good idea of what your pain is.  Also, another classic along these lines is when I ask them their pain level and they say "Oh, it's not bad, about 8/10". I try to tell them they don't look like they're in that much pain. Then they say they thought "0" was the highest, so then they tell you their revised pain is 4/10!?! (Shouldn't it be 2/10?). I usually subtract 2-4 points from what they tell me. Low pain tolerance.

RUNNER: They usually can't accurately grade their pain level either because they deal with pushing themselves daily through "pain" just to run. They usually grade low on their pain level, so I usually add 2-4 points to them because they're afraid I'll tell them to stop running if the pain level is too high. High pain tolerance. 

Me: "How are you doing with your home exercises I gave you?".

PATIENT: “ No problems at all … what were they again?”. Speaks for itself doesn't it? Of course you have no problems with exercises that you don’t do. Or the classic is when I ask the patient to show me how they've been doing their exercises at home. They look at me like a deer in the headlights and they respond with "I don't have my exercise sheet with me"! Now, they are supposed to be doing the 3-5 exercises I gave them 2-3 times per day for the past 5 days. Don't you think their memory would be a LITTLE better? 

RUNNER: "Ok, I guess, but they're too, I did 100 instead of 30...and used 10# instead of 3#...and I tried testing out my knee on a hill run instead of a flat track, but it really hurt on the way down so I only did 5 repeats".

Speaking of memory, I had a patient just tell me this past week "I heard blueberries are good for you, but I can't remember why". My response was, "Well, apparently, you aren't eating them!".

ME: “How would you describe your pain?

PATIENT: “A constant and unrelenting pain”

RUNNER: "A constant and unrelenting ache"

ME: “Where is the ache now?”

BOTH: “Nowhere at the moment” 

I just shake my head. Someday I'll write a book. Meanwhile, my 9 out of 10 ankle pain is telling me to do my exercises, but I think I'll go for a trail run instead. You know, I think that constant rolling them over on rocks and roots keeps them loose. Why don't my patients take their rehab as seriously?

I'll see you all on the roads - AL 

"One child lost is too child saved can change the world"

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