Let go to learn, science- based Physiotherapy.

 When a scientific disciple is “Soft” it invariably has schools of thoughts.  Physiotherapy is no exception to this. In our field, we refer to these different perspectives as approaches, named after their proponents, or sometimes using names that sound scientific like craniosacral therapy or sensory integration.  

In medicine, well in biology finding casual pathways is difficult, probably easy if it's infectious disease.  As the systems are complex and nonlinear what are the causes for the symptoms is difficult to ascertain. This is compounded by the 2 uniquely complex systems we deal with: movements and pain. Both are poorly understood by scientist and always make clinician feel like they have understood them even if we don’t have a clue.  

Birth of Approaches in neurology:  

As theories on how movements are controlled in healthy individuals were developed- clever PTs with intuition, and experience developed ways to use that in neuro-rehabilitation. From proximal to distal, cephalic to caudal, developmental sequences, facilitation to inhibition with sensory inputs were some of the ideas which were fixed in different manner to invent approaches.  

If you look closely these approaches looked at sensory systems as the dominant boss of movements. Dealing with sensory systems alone has the advantage of dealing with a complex system. It makes the approaches which were developed look clean and probabilistic.  

 They rarely talked about the perceptual systems, learning, importance of practice to change the system, long term change or patient centric change. These are complex phenomenon and need far more than just facilitation or inhibition, proximal to distal.  

When never understanding of movement control and behavior started emerging, which took into the account the complexity of the system, we have a different set of schools or approaches.   
 
As we have empirically tested these “approaches” and we have a slightly clearer path to walk forward. So, what does this mean? It means the schools or approaches must go to history of PT. It means from Bobath to pseudoscience like sensory integration should be in our history of PT not in syllabus. They should all go the sterilizer way- you know the one we sterilized the syringes and needle for injection. 

Sadly, that is not going to happen, we are unable to throw them out. When I was small all the hospitals will have a sterilizer.  Can we change:
When I taught at a college in Pondicherry some years ago, the focus of the entire day was on encouraging students to think critically and identify flaws in their judgments. One topic of discussion was the supposed effects of ultrasound on tissue. I questioned why ultrasound couldn't produce any of the intended effects, and someone responded by referring to experiments on how cavitation is generated when applied to tissue. They argued that if there were such experiments, how could I claim it was wrong? 

I pointed out that while we had indeed read about those experiments, it was worth noting that they were all conducted in vitro. However, when in vivo experiments were conducted on live humans, cavitation could not be observed. 

Curious about the reasons behind the lack of cavitation in live human experiments, I posed the question to the group. However, since it was an open question, I opted not to provide an immediate answer here. I invited the five people who read this to think about it and respond to me via WhatsApp. 

During the thinking workshop we had, I had a valuable experience. I cannot say for certain whether anyone liked it or had a change in their thinking. However, what saddened me was the concluding remark during the vote of thanks given by a staff member. They emphasized that everything discussed throughout the day was merely a school of thought. I had to use so much energy to stand up and tell him ““He is the best idiot I have ever seen in my life", but did not. I still don’t know why I did not.        What to do to change: 

Being angry aside, I think the PT staff was afraid to let go of Ultrasound, PNF and all other things I was poop poohing on that day. We are afraid, to say something is wrong or right. Lack of this confidence sadly stops from developing interesting never ideas. We still think US, IFT, Bobath and all we learn in school is PT. Not really as you know what makes your patient better is PT. Let go, we will grow. Let go nothing is ours. Bobath is not our god, let go, Traction and IFT are just a bunch of motors and wires, they are not PT, let go. Let go off most of the syllabus and we will grow. Let go- better science which helps patients will occupy the space. 

 

With so much love Hariohm

 
 Let's see school of thoughts in relation to pain some other time as this one is long. 

 

Is practicing Evidence based Physiotherapy in this system possible?

Practicing evidence-based physiotherapy in India can be challenging due to the prevalent top-down model where medical officers prescribe treatment plans and physiotherapists simply follow them. This approach is common in both private and government hospitals. However, despite these constraints, there are ways to incorporate evidence-based practice into our work:  
I believe we should be “ready” so these are the mind set a novice PT should have. Experts, seniors, PhDs, people who attended workshop with a white person teaching NDT, rubbing, sticker boys, fascia pullers and professors are beyond redemption. This is not for you.    

1. Treat every patient like a VIP: Adopt the mindset that you are providing care to someone as important as your own mother. This perspective will motivate you to find ways to deliver high-value care within the existing system.
2. Embrace the evolving nature of knowledge: Recognize that knowledge in healthcare is constantly evolving, and new research findings emerge over time. Make a habit of reading scientific literature and staying updated with the latest research in your field. This will enable you to stay abreast of current best practices and gradually incorporate new evidence into your treatments. 
3. Understand what constitutes high-value care: Many healthcare professionals complain about a lack of autonomy, but when asked about high-value care for specific conditions like low back pain or osteoarthritis of the knee, Stroke rehabilitation, they often lack awareness beyond what they were taught in school. Educate yourself about the latest evidence-based interventions and techniques for different conditions to provide the best possible care to your patients.
4. A good starting point for high value care is to assume what you learnt in college like special test, IFT, traction, do and don't, dosage, and much more are complete bullocks 
5. Remember you are in home-based rehabilitation- you have lots of autonomy. Don’t be afraid to through away passive low value care. Don’t listen to “seniors” who keep on telling patients “Want” passive treatment. Not really. Everyone wants to achieve something and patients will be happy if you make them achieve goals they want. If you are so afraid to change your whole practice- start small. Spend some time in passive care and majority of the time in high value care 
6. If you have a clinic, continue to incorporate the prescribed treatments, but supplement them with high-value care interventions. Spending more time with patients and providing additional therapy will likely be appreciated. To embrace high-value care, start with small changes while dedicating the majority of your time to interventions that deliver meaningful outcomes. 
7. Learning high value care for around 10 conditions should not be difficult.  So, take some time to learn. Don’t complicate. Clinical medicine is learning some exercise and a ton of common sense. Sadly, our common sense is ruined by college- so unlearn what you learnt- starting with assuming what you learnt in school is bullocks.   
8. Avoid falling into the trap of blaming the system for its shortcomings. While the system may not readily support change, focus on the positive impact you can have on your patients. Celebrate the small changes you make, as they can prevent cynicism from creeping in. Remember that delivering high-value care is challenging but essential. Embrace the difficulty as an opportunity to apply scientific knowledge and make a real difference for your patients.  
9. Change is a marathon. Results take time. Be patient.   
   
   I would like to have a round 10 points- well seems i ran out of ideas or got bored.
   PS- probably you should also not listen to me and not follow these.
   Love
   K Hariom
   
   
   
   

1. 
   I would like to have a round 10 points- well seems i ran out of ideas or got bored.
   PS- probably you should also not listen to me and not follow these.
   Love
   K Hariom
   
   
   
   
   
   
   

Sitzfleisch

 Do I need a “proper chair” or an ergonomically designed chair for my workspace? The short answer is of course not, and even shorter answer is NO 

If you read about the history of chairs, you will see like most things the Egyptian aristocracy used chairs not stools (that is stools with back rest. And most of us, the mere mortals who don’t workshop cats as gods- sat on ground, squatted in the ground (on which we even published a research article) or on something without back rest. In the 19th century, Michael Thonet, a carpenter, played a significant role in popularizing chairs among the masses through his innovative bentwood technique. However, it's worth noting that chairs remained relatively uncommon in many regions until more recent times. For example, when I was growing up (in the 0s and 80s), chairs were not commonly found in places like cinemas, marriage halls, or rural households. My next-door Neighbours – who had the biggest house in the block had one easy chair and everyone else sat on the floor.  

The proliferation of chairs can be attributed to various factors, including the advent of plastic materials, socio-economic advancements, and changing cultural norms. These factors have contributed to chairs becoming a ubiquitous piece of furniture in modern households and workplaces. 

The advent of comfortable, ergonomically designed chairs brought with it a new set of concerns and fearmongering. Fearmongering plays a significant role in capitalism, including in the field of medicine. As a result, we witnessed headlines proclaiming that "sitting is the new smoking," creating a sense of exaggerated risk. While it is true that prolonged sitting is not ideal for our health, the severity of its negative effects may have been overstated by fear-mongers. 

Furthermore, the fearmongering around sitting gave rise to a cottage industry focused on educating people about the "proper" way to sit. This included guidelines on sitting posture and warnings against sitting on the floor due to supposed risks of developing osteoarthritis ("OA knee cooties"). The entire field of ergonomics thrived as a result, with an abundance of products and advice on finding the best chair. 

It is important to maintain a balanced perspective and consider individual comfort and needs when choosing seating options. While ergonomic considerations can be beneficial for some, it is essential to separate genuine health concerns from fear-driven marketing tactics. 

The real issues related to sitting for extended periods stem from the fact that humans have evolved to engage in various activities, including extended periods of sitting. Studies conducted on hunter-gatherer communities have revealed that humans historically spent many hours sitting. Even before the rise of office work, individuals engaged in physically demanding tasks such as farming, followed by periods of rest and sitting. 

Therefore, sitting itself is not the problem. The issue arises from our modern lifestyle, where we often lack physical activity and prolonged sedentary behavior becomes the norm. Our bodies are designed to be active and engage in a range of movements. When we don't have enough physical work or movement in our daily lives, it can negatively impact our overall well-being. 

The key is to strike a balance between sitting and physical activity. Incorporating regular exercise, movement breaks, and maintaining an active lifestyle can help counteract the potential negative effects of prolonged sitting. It is important to recognize the importance of overall physical engagement rather than solely focusing on the act of sitting itself. 
 

1. While the following suggestions are not evidence-based, they can be considered as practical ideas to incorporate more movement and avoid prolonged sitting during office work: 

• Consider using a stool instead of a traditional chair for your office work. This can help improve your sitting endurance by providing less comfort and encouraging you to get up and move after some time. 
• Take regular standing breaks and incorporate squats into your routine. Standing up and doing some squats can help break up long periods of sitting and engage your muscles. 
• Opt for a non-comfy chair that doesn't promote extended sitting. A chair that lacks excessive comfort can discourage prolonged sitting and prompt you to stand up and move around more frequently. 
• Avoid keeping everything you need within easy reach on your desk. By placing items like a water bottle or physical files slightly farther away, you are more likely to get up and move occasionally to retrieve them. 
• Make a pact with your colleagues to motivate each other to move every hour or so. Establish a system where you remind each other to take short breaks, stretch, or go for a quick walk to break up sedentary periods. 
• Remember that taking breaks is essential for your well-being. Remind yourself that the tasks at hand are not life-or-death situations, and taking a break won't significantly impact your work. Step away from your laptop and give yourself the opportunity to recharge and rejuvenate. 
• It's important to note that while these suggestions may help promote movement and reduce prolonged sitting, they are not scientifically proven approaches. It's always advisable to consult with healthcare professionals or ergonomic experts for evidence-based recommendations on improving your work environment and overall well-being. 
• if you are in-charge type- throw away that ergonomic expert and get a stick (read the previous suggestion also)

 

Much more- but this blog has become long so.. enough 

 

So where did i get these information and ideas: evolutionary psychology books like- how the mind works by steven pinker,

Exercised: Why Something We Never Evolved to Do Is Healthy and Rewarding- Lieberman  

and my crazy ideas from reading