Time to think of education

Time to think of education

One of the sad news I read today was in The Hindu (click here to read). It talks about why children in rural India die of diarrhoea and pneumonia based on a JAMA article. It has 2 lessons I believe: 1- how poor our training of health workers in India and 2- this is for all the therapist- this is what we mean by burden of illness and priority public health.

One of the reasons I am writing this blog is a selfish reason but with some value to all of us. There are very simple methods to prevent diarrhoea related death. The WHO has given clear guidelines of how to manage these patients but alas the health workers (including physicians) had very little idea on management principles.   The reasons can be laziness of the health workers, poor training, plain stupidity and lack of empathy for poor.

But I believe one of the major reasons forgetting what medical professional’s important tool- education and empowering patients. What it means is the health care workers don’t want to take the time to make the patient understand the disease, simple solution they ought to do rather they just prescribe something and hope it will all go away.  (I see similarity in therapist treatment of pain also but that is for another time). Of course the study also highlighted the over treatment (just like us PTs) and prescribing drugs for people who just were not sick.

The sad part is I don’t see and association of health workers or physicians making a hue and cry- I can remember when someone told on TV the stupidity of screening they all were up with arms, but …well fill.  I am not going to talk about the 2 issue. (This is for all the therapist- this is what we mean by burden of illness and priority public health.)

So what is the selfish reason-well I am going to give some links to how to treat diarrhoea from Cochrane and well it is Tamil. Please read it and also spread the message.

1. 1.       தீவிர வயிற்று போக்கிற்கு (polymer) பலபடி சார்ந்த வாய்வழி அளிக்கப்படும் நீரேற்றல் கரைசல்கள் (ORS)
2. 2.    குழந்தைகளின் கடுமையான வயிற்றுப் போக்கால் ஏற்படும் நீரிழப்புக்கு வாய்வழி குறைக்கப்பட்ட ஊடமைச் செறிவு (osmolarity) வாய்வழி மீள்நீரூட்டம் (rehydration) சிகிச்சை
3. 3.    குழந்தைகளில் பேதி சிகிச்சைக்கு வாய்வழி துத்தநாகம் கூடுதல் உட்கொள்ளல்

The stupidity of assuming we are alternative medicine

The stupidity of assuming we are alternative medicine

I was today shocked to read a bunch of idiots have lobbied us to be part of AUYSH (for people who don’t know AUYSH- it is the clubbing of all magical medicine from India and one nonsense from Germany). This is what happens if people who are lobbying and in the politics of associations are uneducated and have a poor understanding of medicine.

There are only 2 types of medicine-1. Modern medicine and 2. traditional medicine. Modern medicine is an evolution of traditional medicine and it should be not called allopathy or English medicine. What do I mean by evolution of traditional medicine? Modern medicine developed as we find more science in our traditional methods of treating. Classical example is treatment of malaria using chloroquine.  It is a common method of treating malaria derived from traditional knowledge and it transformed into modern medicine because it has been put through scientific rigor rather than just believing it to be the treatment because someone in the 2 century or some sidhar wrote it in 10 century.  

Physiotherapy is part of modern medicine. Why? Because we don’t believe in the five element theory of disease as in acupuncture or Ayurveda, or some fantastic pseudo-science –“like cures like” (homeopathy) or vertebral subulxation (magic from north America- chiropractic)  and follow modern physiology. We do trials to confirm and deny our science (read Cochrane summaries).  But you will not read those in traditional medicine, were the founders and the bibles which are written in a different era is still considered as the truth.  Modern medicine is dynamic; it changes with new findings and research.

So, pray who are we. We are should be and are department of physical medicine and rehabilitation.  We are part of a team of health provider including physicians, surgeons (as in acute physical medicine- example, cardiorespiratory PT), with OT, clinical psychologist and others as in case of Neuro-rehabilitation. I hope I don’t have to elaborate on ortho-PT (where I believe we should be primary health care providers in case of cold orthopedics and part of the team in traumatolgy). We should be striving for these issues. We should learn to be primary source of knowledge in these areas and work as part of the medical team. A classical example is dental. T they are part of the modern medicine and at the same time have created a knowledge base of dentistry which is unique to them (remember some of their principles will be similar to ortho).

Sensible people should educate our presidents, prime ministers and other cabinet ministers of our association

http://static.fjcdn.com/pictures/Amen_b6a004_4599236.png

The importance of using the right language while talking science

The importance of using the right language while talking science

One of the biggest concern for me in PT (especially in India) is the advent of newer terminologies in describing- well either imaginary things or already existing things.

1.       The first example is a classic- the trigger point release. When I went to college it was called like in any sensible medical literature as tender spot. Along came the 2000s and with than came in fancy treatment-  TRp release.

The first issue is whether it is the Ashi point as they called in magic (I am referring to acupuncture) or trigger point as they call in some neo-magic (I am referring to chiro or something) is –why do we have to call it as trigger point and not tenderness. There are some half baked studies which looked into the histopathology of it and proven- well we don’t know for sure. However, there are also many studies which have consistently proven that reliability of finding them poor at the best. The next issue with the word release- what the hell is wrong with us to call something as release. These words come from a magical treatment called chiropractors – who studied magic rather than physiology when they wrote the term. However, we now are in the era of -free or easy access to knowledge, and we should know better. Muscle or pain is not something you release, it is such a complex phenomenon it is scholars are grappling with it for many years, but we are just, “I released the trigger point and the patient is alright”. This reflects very poorly on worth, we are more intelligent then that. 

                So, pray what should we refer to ask my friend? Well, the muscles relaxes, beautifully named as “Hold and relax” by Knott and Voss. Relaxation is a phenomenon of the muscle- not release. As for trigger point, well pray –Sarwathi visits us and we all read medical literature other than Facebook posts.

Of course there are 100s of therapist who are going to say- well this guy is a moron, I have seen it, I have seen people getting better etc.

     

2.       Bone has eroded- (you know what we say in our vernacular). It is high time we talk about back pain, OA as a disease not as pathology. Talking it as a p athology makes you want to change the pathology, it creates so much anxiety in the patients mind. We need to have a better language in patient education regarding these diseases. Just, keep the x-ray or MRI in the cover rather than seeing it.

3.       Facebook- it is a proper noun- it cannot be called as முக- நூல்- come on people Hariohm is Hariohm in any language. Thank god we did not translate- google,  cognizant (which again can be translated unlike google)

4.            

My 2 cents on associations of physiotherapy

I usually don’t write about any of the associations in India or Tamil Nadu (TN). Reason one, well I have a life. But this Saturday afternoon, did not have anything to say so- here is my take on our precious associations.

The first thing I find in TN is there are 2 many associations. The general feeling I get is everyone seem to think they are here to lead and they don’t want to follow any one. The second is everyone thinks there aim is more – how do I put it- has a higher purpose.

The first thing I see all the associations do is –well this is in vogue for the past few years – is conduct a National conference. I don’t have anything against it – but I can distinctively remember in the late 90s we all complained that is what IAP did and nothing else. Well the all the associations have fallen into the same pattern. As we say in non-linear theory- they have all fallen into the same attractor state.

The next thing I remember what all the association meetings were about:

1.       Getting government job

2.       Getting a council

3.       Talking bad about-The Man (the one person who is stopping  us from achieving the goal)

I have not gone to any meeting for quite some time but, I am assuming this is what is discussed and also from all the cry babies writing in face book.  Well what is wrong you ask me? Well don’t worry any of the people who took the time to read this is going to get it. We are more in numbers and the government jobs are never going to enough. Please understand medical economics if you are one of those “leaders”. The government’s policy on health is complex and it depends on burden of illness, resource and who can lobby well. So don’t be gullible in thinking 10- 200 people are going to get you to change all that easily.

Getting the council, Well a must need for PTs but it is not a panacea for all our woes. It is not going to bring more jobs, more money, not change your salary if you are working even in a college. Come on people read market economy; we have a right wing government in the centre and a centre to right in TN.

Well not writing about the last one because- I may be the man in the next meeting who is stopping you from growing.

What do I think associations should do?

Well the good things first- I see some association doing clinical meeting or CME. AS you can imagine I think that is a wonderful step. However, my personal opinion is get people from your own city, own association to do the talk. (This is also for the conferences) Why call some idiot from Mumbai or some place else).

Lots of associations have a dedicated people –who are leaders and follower- but I just can’t get over the feeling there is a lack in understanding of rudimentary things. I can remember being like that also after when I came out of college. Use them for something constrictive and think real issues- like training us to do be first contact practioners before asking for that.

Stop telling us diploma is bad, correspondence course is bad- of course we know that, more importantly that is how most of the regular colleges are running. Sad part is some of the “leader” have got there degree by not stepping into the college even to use the loo.

Stop being talk shops. I see many of the association becoming talk shops-getting the troops rallied up all the bull shit but with no substance. The common thing I see people talk is the universal cliché since Marx times- “Unity”. When the great Marx said unity he wrote a 3 volume book- which after trying for 7 years could not understand it- sold it back to the old book store. But most of the time when I see therapist say it is without doubt- without any substances. Why do you want us to be in union? Fight for what? What right am i not given? What is your goal? If your goal is get united and fight for unity, justice, get a council, get us jobs- well may be I will join justice the league  and fight crime at night along with superman et al.   

Of course there are also other association/ cults in this mess- the NDT cult, Mulligan cult and the overall manual therapist cult-well don’t get me started on those idiots.

Disclaimer: I have participated in some associations functioning before realizing –what a waste of my energy and intellect.

Homer Simpson- Old people don't need companionship. They need to be isolated and studied so it can be determined what nutrients they have that might be extracted for our personal use. 

What’s up with Supraspinatus?

What’s up with Supraspinatus?

I always think supraspinatus epitomises what is wrong with physiotherapy.

Well what is the connection between Supraspinatus and physiotherapy? Well let me start with the story of supraspinatus. As we all know it is small muscle which is oriented horizontally and present around the top of the shoulder joint. 

The problem starts when we ask the question what is its action. Invariably the answer is initiator of abduction or works up to 15 degrees of abduction you stupid is the answer. It is how the anatomist taught me when i went to college (long time ago) and it is what is taught now also. The anatomy book we refer still says this as the answer (and they will not reply me for all the mails I have written regarding it).

Well what is wrong with the answer- well from the 60s people started identifying supraspinatus as abductor rather than a specialised initiator. In his classic book “muscle alive” Basmajian wrote in the 80s how we are repeatedly mistaking supraspinatus as an initiator rather than as a synergist in abduction. Other anatomy books have followed suit including text books like “wheelers text book of ortho”, biomechanics books etc.

However, I am not sure why PTs, the people who are concerned with movement seem to make this wrong assumption after all these years. Even experts! in sport and manual therapy are making this error.

It begs the question-does supraspinatus a symbol of our antiquated knowledge?

Homer Simpson: Lord help me, I’m just not that bright.”

Wieners and other cry babies and their diagnostic tests

Wieners and other cry babies and their diagnostic tests

Well this time I am writing about my favorite subject- criticizing anyone- but this time medical practice in TN (including fancy nonsense like sidha, homeopathy and all the pathies including Physiotherapy).

I am writing this after a TV program in TN (which fortunately I did not watch) which created a controversy and wieners in the medical profession are crying about it (including PTs ).

The first relates to overuse of diagnosis in practice and getting substantial illegal money for it. This again is also prevalent in PT and other pathies. I am not going into the issues highlighted in the program as we all know it is an open secret -that for every medical test the medical practioner gets at least 50 % as illegal black money (it should not be called commission- as it might be a legal tender for example what a real estate agent gets).
The first issue in requesting a diagnostic test is that it should increase your probability of the possible disease. Also we should have an assumption (a pre-test probability) that this person may be suffering from this particular disease and then do the test. You should not do it wily nily on all the patients. For example you do a test for malaria on patients with symptoms like paroxysmal symptoms of fever shivering body pain etc. You don’t do it on all the patients who come to the GP with fever. Or you don’t do preg-test for all the women who enter the OBG clinic.

However, this is what happens in case of LBP- either a MRI or a X-ray is ordered by –well any idiot with a pen and thinks he/ she is a doctor (which again includes PTs and other nonsensical profession like sidha etc). Why pray is a problem? - The biggest problem is we are going to have over diagnosis and lots of false positive. Second is the harm the patient is exposed to- the X-ray is not a torch light. Third is harm of teaching an anatomical or a pathological model of pain which is the biggest harm i presume, as it might impede the prognosis of the patient.
The second issue is a test (like an x-ray or MRI) should change your treatment after the patient undergoes it. For example, if you have a patient with LBP and you are thinking of exercise and some passive treatment like IFT or manual therapy after the patient has got an x-ray or MRI the treatment should change. I am pretty sure after X-ray none of PT management is going to change (if there is no red flag). A second example can be an x-ray for OA knee patient- will the treatment change because the patient has a joint space narrowing or osteophyte- the answer is no for any treatment. However, when a patient with OA is not getting better, his joint movements are very restrictive  and when you are contemplating surgery then you need a x-ray as it may influence your change in management- that is joint replacement.

Hence, most of the time if you are ordering for an x-ray – you should be thinking – does this patient has a red flag. That is we should be having a big concern or suspicion that the patient is having a systemic disease and that is causing the pain. Next if you are ordering for a MRI- probably the patient is being posted for surgery- as you can imagine surgery is different treatment than conservative management.

So cry babies in medicine should first learn medical theories and best practice methods and then cry wolf. The next post we will see why screening is good for only doctors and hospitals and not for patients.

So for medical professionals the lessons are if most of your patients with pain are getting an X-ray- you are over utilizing diagnostic tools. If you most of your patient are getting a MRI (for pain) the you are not only a moron you are also a cheat and a criminal (as you are also getting illegal money from the center)

For patients-  

1. Ask your doctor why and how will the “test” will help me in getting better

2. Even for a simple blood test ask the 101 question you ask you cable operator when he comes to collect the paltry sum of 100rs

3. Tell your doctor to f!@# off he tells you to get the test in his favorite lab-well go and complain in a consumer forum or just write nasty things about the system on the net- see what happened when a uneducated said nasty things about doctors

4.  Remember medicine is also a business not a noble profession (that was 30 years back) so shout at them when the service is poor or you are not satisfied- as in case of with your mobile phone operator

5. Read consumer summaries and guidelines issues to reputed sites like Cochrane (http://www.thecochranelibrary.com/view/0/index.html)

Reference:

1.       Appropriate use of diagnostic imaging in low back pain: a reminder that unnecessary imaging may do as much harm as good

Homer simpson: “What's the point of going out? We're just gonna wind up back here anyway.”

A rhetorical question

A rhetorical question

A favorite question of mine is- if you a patient has say LBP or PA shoulder should the patient be seen by a therapist and asked to get an appointment for 5- 10 days or get a package ( up to 15000rs in chennai) until endpoint of the disease or pain.

The question is why should they attend a PT department daily rather than taking some pain killer and doing the exercise at home if needed? Isn’t it cheaper to spend 20 rs on some NSAIDS and do some exercise at home!

Here are some of the answers I have got from PTs. They have to attend a PT session because of-

1.     Is it because- supervised exercise is needed or more important?

2.     US, SWD, IFT, manual therapy is better than NSAIDS

3.     The adverse effects are less in PT than drugs (really)

4.     Others- please specify---------------------------------------

Please comment you answer.

Love

Hariohm

If they think I'm going to stop at that stop sign, they're sadly mistaken! --Homer Simpson