Controlling your health. Part 1

Health and fitness is, without a doubt, one of the fastest growing fields in healthcare; and for good reason. The top six killers around the globe are heart disease, stroke, COPD, cancer, accidents and diabetes. What do most of these have in common? They are lifestyle based. Of course there will be medical elements to some of them but its hard to argue that a healthy lifestyle wouldn’t be beneficial.

I believe health and fitness is a state of balance between body and mind. This equilibrium in-duality  is accomplished by achieving wellness in four primary categories:

1. Muscles and joints

2. Cardiovascular system

3. Dietary habits

4.Mental health

When these four systems are healthy and happy, I believe you are in a balanced state of health and fitness. Doing so can be challenging, especially if you are lacking in self-efficacy. It will be our goal in this three-part series to get to grips with your own perception of health and self-belief. Your mindset creates, controls and influences your health, It is your beliefs, values and expectations. Ultimately, you will identify how you perceive health on three separate levels.

1.  Internal perception
2.  External perception
3.  Change perception

Once identified you will allow you to have an idea of your health expectations and beliefs. By knowing what you believe you can begin to halt destructive behaviors and begin to take action to improve your health. You are the ruler of your temple, no-body else manages your body but you.

 Internal health perception

In practice I have witnessed the difference between those who believe they can and those who don’t. The difference is huge in terms of recovery and relapse.We all know someone  that has overcome a great health crisis. Were they positive or pessimistic?

Pessimism, defined as stress resulting from hostility, resentment and despair, has been linked to a host of diseases. Men between the age of 40-55 who have high levels of hostility have a 42% higher risk of death, so relax guys because the stress is literally killing you.

Identify your internal health perception

For each of the following mark the most appropriate answer. Do this in private and be honest with yourself, knowing that you won’t be judged. Score them from 0-10. 0 being no confidence and 10 being maximum confidence.

1. My willingness to follow a good nutritional program in order to maximize my body’s healing abilities.
2. My willingness to exercise my body in order reach maximum recovery.
3. My belief in my ability to use focusing techniques to accomplish my goals in health.
4. My belief in my ability to calm my stress issues and use that energy to succeed in my physical healing.
5. My belief in my inner strength to heal my body.

Scoring your internal health perception

0-30 Low confidence in self direction

31-40 Average confidence in self direction

41-45 High confidence in self direction

45-50 Very high confidence in self direction

Understanding your score

Our perception of our health is so important to how we live, work and play. It’s within our beliefs and expectations by which we base our decisions concerning our well being. If we believe in a system there is a much better chance that it will work.

Take for example, chicken noodle soup for a common cold or flu. If you believe in it chances are it will help. Your internal health perception is how much you believe in yourself as the manager of your health and body. Your belief is important if you don’t believe in yourself you don’t have control. With that being said, there are cases and issues outside of such control. Hereditary disease or any uncontrollable events may also negatively impact your health. These are not your fault and there is no point in beating yourself up over it but instead focus on the future by what you can do now.

People who score low on this test need to understand that they are accountable. Now there is no reason to feel guilt but if you do feel guilt it is because you have violated one of your biggest standards. Now that you have acknowledged that move on!  Commit yourself to making sure the behavior doesn’t persist.Use the guilt as leverage to never violate your own standard even again.

If your scored high, congrats. Scoring high is for the most part a great thing It means that you take responsibility for your health The higher the score the more likely you are to:

1.Acknowledge your perceptions

2.Own your perceptions

3.Find solutions of your health issues.

4.Make the solutions happen

The down side to having a high score is that you may be overly self-sufficient. In this case, you may fail to seek advice or mentorship. You may fail to reach out to others that have a wealth of information. Again if the health concern you may have isn’t your fault (blindness, heart disease etc) don’t pressure yourself. Blaming yourself for issues outside your control is worthless. Focus on what you can do now to make a better future. Hold yourself accountable for your actions from here on.

In the next part of this series we will be looking at your external health perception. How you view others in regards to your health and wellbeing. If you feel comfortable leave your scores below; its alway nice to compare notes. There is nothing wrong with a low score as long as you own up to it and seek out advice or support.

In Health

Dr Anthony.

Acknowledgments.

Thank you to Doctor Frank Lawless for his health perception test.

3 Major Myths Concerning Back Pain

1. The need for an accurate diagnosis
2. The need to rest until pain is gone
3. The pain will lead to chronic disability

The need for accurate diagnosis

The spine is a unique structure and is often subject to debate in various circles of study.  During your lifetime you have about a 70% chance of developing acute lumber pain.  I am sure if you have experienced significant pain in your back, you have had concerns regarding accurate diagnosis of where the pain is coming from.  In fact, many form their own lay mans version of a structural cause, such as the muscles, ligaments or disc.  What is interesting is that research shows that none of these can accurately be diagnosed as a source of pain.  What is even more important is that structural causes need not be identified in 85-90% of back pain patients for a successful outcome to result.  It should put you at ease knowing that serious medical disease resulting in pain is less than 2% of all back pain causes.  What’s more exciting is that the fact that these 2% maybe ruled out through a proper history and simple exam.  So what is causing the pain?

A better question is to ask “what is my pain trying to tell me?”  The perception that pain is a negative sensation is harmful; pain is simply trying to tell you that if you keep doing something (such as lifting improperly a certain way) the tissue may be harmed.  It doesn’t mean you have already harmed the tissue.  In the case of a simple back ache, pain doesn’t equal harm!  Therefore the pain is simply telling you to be more active or aware of your movements.

Need to rest until pain is gone.

The biomedical model has often prescribed bed rest for lower back pain (LBP); however multiple studies have shown bed rest to be more harmful than good.  In fact, 2-3 days bed rest is maximum for acute, simple back aches.  More over this should only be recommended when pain is severe.  Bed rest isn’t treatment for the pain; it is a consequence of the pain.  Even though uncomfortable, being astutely active is the best and most efficient form of treatment. For simple back pain when should you use bed rest?  If the pain is severe (9/10) then consider it, but only for a few days (remember rest isn’t always best).  Excessive bed rest may lead to chronic disability.

People experiencing back pain often become fearful that the pain will cause serious disability.  Such disability is highly unlikely; moreover, people who remain positive, active, and motivated are likely to recover quickly.  People who equate hurt to harm or exaggerate pain tend to become worse.  When a person experiencing back pain stops becoming active, the joints and muscles become inactive, this inactivity leads to de-conditioning and the de-conditioning results and more prolonged pain.  Do you see the downward spiral?  So how do we keep the pain from becoming chronic?

1. Remain active
2. Exercise regularly
3. Remember hurt doesn’t equal harm

If you are fearful, use a quota-based approach, gradually increase your activity in a step wise manner.  Limit activity by quota (set-reps) not pain.  Gradually encounter the things you fear and are safe and low load environment.  You can’t get over the fear of running by sitting on the ground, you get over it one step at a time!

Summary

1. Bed rest may have harmful effects on back pain.
2. The benefit of activity exceeds the risk the rest.  Swimming and walking are great for active recovery
3. Hurt doesn’t equal harm.
4. Flare-ups aren’t a failure they are expected.  Simple movements like a cat crawl or back bridge can immediately reduce symptoms.
5. Exercise is the best way to prevent future back pain; however, 25% of patients fail at sticking to a plan.  What can you do to stay motivated?

Acknowledgements.

Special thanks to Craig Liebenson for valuable insight

Controversy: Imaging, is it helping your patient or wallet?

Controversy: Imaging, is it helping your patient or wallet?

When diagnosing the culprit of lower back pain, many clinicians rely on diagnostic imaging (i.e.: x-ray, MRI, CT). Lumbar pain is reassuringly benign, 85-90% of the time. Lumbar pain involving nerve compression comprises 10% of lumbar pain patients. Sinister or serious disease make up the remaining 2% of lumbar pain patients. The great news is that these ‘sinister’ conditions are ruled out by a proper history and exam. However, many clinicians still seem to be ordering imaging during the initial exam. The question often raised is

“structural pathology is often evident in images, so why wouldn’t we (the clinician) want to identify such abnormalities?”

While structural pathologies do have there place in medicine, they usually have little to do with lower back pain. In fact, most lumbar pain patients do not have a structural pathology that can be precisely identified as being a cause of their symptoms. McGuirk et-al found that 1.4% of lumbar pain patients had serious causes as a result of their lumbar pain, but they were suspected from the initial exam and history.

What about disc herniation?

Because the false positive rates are so high, in identifying a herniated disc, it makes imaging inappropriate as a screening procedure. Moreover, it can lead to labelling thus allowing the patient to assume a sick role or cause the doctor to prescribe unnecessary treatment. In a study performed by Bonenstein et-al, 67 asymptomatic individuals received MRI’s. The results were staggering, in that, 31% of them showed abnormality of the disc or spinal canal. Moreover, additional studies showed that these abnormalities didn’t predict a greater chance of future problems. Multiple studies have also shown that common “positive” findings are present in 28% to 50% of people with no pain at all! Disc herniations have a tendency to resolve in a natural process without surgery. But, what about the herniations that require surgery? The Danish guidelines show the following as being surgical indicators for herniated discs. 1: No improvement after 4-6 weeks 2: Progressive weakness in the leg 3: Leg symptom remains severe despite treatment and medication 4: There is a positive correlation between clinical findings and imaging reports. What about spinal degeneration (decay)? Again this is a term that instils fear into a patient. Disc degeneration is demonstrated with equal properties between those with and without pain. The prevalence of disc degeneration in people without pain and in their middle ages ranges from 46% to 93%! Therefore there is little correlation between radiological signs of degeneration and clinical symptoms.

When is imaging appropriate?

Most acute lumbar pain patients resolve quickly and with little intervention. In fact, It has been shown time and time again that reassurance, simple pain relief and staying active, is the best strategy for managing active lumbar pain. If there are red flags (sinister conditions) present, they should be picked up during the initial history and exam. Red flags of the serious disease are as follows: Mri of the back 1: Age younger than 20, older than 50 2: Trauma 3: History of cancer 4: Night pain (unremitting) 5: Fevers 6: Weight loss (unexplained)\ 7: IV drug use 8: Cortico steroid use 9: Recent infection 10: Cavda Eqvina 11: Generalised Systemic Disease (diabetes) 12: Saddle Anesthesia 13: Motor weakness of lower limbs 14: Sphincter Disturbance 15: Failure of 4 weeks conservative care Given these guidelines we are able to form a simple strategy. If there are no red flags, consider: 1: Reassuring the patient no serious disease is present 2: Relieve and reduce pain (simple analgesics, manipulation) 3: Reactivation (stay active, no bed rest) If there are red flags present consider the following: 1: Imaging 2: Lab work 3: Referral Informing your patient that you are able to rule out sinister conditions, even though an exact cause of their pain may not be identified, will register as very reassuring news. Craig Leibenson gives a wonderful analogy for simple back pain:

“liken the pain to a common cold or the pain experienced from gardening for the first time after a long winter”.

Conclusion

In a study by Kendrick, patients who received x-rays were likely to report a longer duration and greater severity of pain. Why reinforce a patient’s belief that they are unwell and cause them to limit their activities and in essence promote a more negative outlook? Yes patient satisfaction may be higher but the patient must be educated on why radiography is unable to improve therapy, decision making, or outcomes. If after 4-6 weeks there is no sign of improved function or red flags are identified from the patients history and exam, then consider (imaging or appropriate refferal). But always remember, a picture of a car doesn’t mean its running.

References. Leibenson C, Rehabilitiation of the spine. 2nd edition: 2007 Bonenstein DG, et-al. The value of MRI of the lumbar spine to predict lumbar pain in asymptomatic subjects. J Bone and Joint Surg 2001:83-A:1306-1311. Boden SD, abnormal MRI of the lumbar spine in people without back pain. N engl J med 1994;2:69. Kendrick D, Radiography of the lumber spine in primary care patients with lower back pain: Randomised controlled trial.  BMJ 2001; 322: 400-405. Jaruik JG, the longitudinal assessment of imaging and disability of the back study.  Spine 2001; 26:1158-1166.

16 simple rules to inner well being

Today I had passed onto me some well meaning axioms that were supposedly written by Buddha. I personally found them enlightening and thought I would share.

1. Take into account that great love and great achievements involve great risk
2. When you lose, don’t lose the lesson
3. Remember that not getting what you want is sometimes a wonderful stroke of luck
4. Learn the rules, so you know how to break them properly
5. Don’t let a little dispute ruin a great relationship
6. When you make a mistake take immediate steps to correct it
7. Spend some time alone everyday
8. Open your arms to change but don’t let  go of your values
9. Remember that silence sometimes is the best answer
10. Live a good and honorable life that way when you are older you can enjoy it a second time
11. A loving atmosphere in your home is the foundation for your life
12. In disagreements with love ones, only focus on the correct situation , don’t bring up the past
13. Share your knowledge, its a great way to achieve immortality
14. Be gentle with the earth
15. Once a year go somewhere you have never been before
16. Follow the 3 R’s

• Respect for self
• Respect for others
• Responsibility for all actions

In life we are merely passengers, so its best not to “back seat” drive. We are architects of our lives and great plans require great work. In many great projects there will be disappointment, discouragement and dissolution. These are nothing but tests and traps. True character is found in times of crisis. Focus on what lies ahead, stick to your true beliefs and values; and you will forge a noble reward. Remember that on the horizon of every dark  and cold winter, lies the promise of a sunny and warm summer.

Mastering Your Pain: Self Care

The word pain evokes a plethora of responses from human beings. However, pain is still in many senses elusive. Many different theories have been presented which attempt to describe, label and categorize pain.

Many current theories point to internal factors being the center of pain, processing and  perception. In other words, the nervous system transports and allows for perception of pain.Moreover, misdirected labeling and deceptive medical diagnosis often focus on external sources as an origin of pain.

The argument is that the patient might not have sufficient strength or endurance and as a result may be causing pain. Insufficient strength or endurance may cause improper movement patterns, which are causing tissue irritation, joint stiffness, deconditioning, and pain.

However, how do patients enter into this cycle? Is it a lack of fundamental movement? Perhaps, how about a lack of strength or endurance? perhaps, but what if it’s simply a lack of motivation? You see, I believe that most musculoskeletal pain (MSP) is a motivation problem first and a movement problem second. Of course, there are exceptions to this, but if you look hard enough at the patients’ history, you will find they deal with pain in one of four ways.

1. They avoid it
2. They deny it
3. They compete with it (boom / bust)
4. They accept and learn from it

Once a patient accepts that pain is their friend and not their enemy, they have taken the first step. Most patients will agree that they have been living life below their true standard or simply being lazy. Once they realize that pain is simply a indicator of something potentially underperforming, they can begin to understand why they need to change their approach. 80% is the why, the remaining 20% is the how.

Rename The Pain

Drop the intensity! What do you think of when you hear the word pain? Probably nothing good. But if we look at how we talk to children when they become injured, what do we hear or call the pain? A boo-boo or an ouchy! What if we did the same thing? If you are sitting right now and experiencing acute back pain, stand up and move around, and call your “pain” a boo-boo. It’s hilarious and immediately shifts your focus.

Own it.

Are you able to own and control your pain through thought process? Absolutely.

1. Identify it. Is the pain (boo-boo) truly there?
2. Realize it’s here to help, not harm.
3. Become very curious about your pain.
4. Be confident that you can handle and control it.

Remember, you can avoid it, deny it, go boom or bust, or you can accept and learn how to change it. Don’t live below your true standard. Be honest with yourself. Who are you? Are you a lazy, unmotivated, sedentary human? Of course not! Your habits may be sedentary or lazy, but inside, you know that’s not you nor is it what you intended. If its a lack of movement or lack of life, why are you or why would you harm yourself? Do yourself a favor and realize that you have the same potential that all human beings have. Strength gives birth to movement and movement defines life.

6 Steps to Motivation: Get rid of the pain for good.

1. Decide what you want to feel like and why you aren’t feeling that now.

Write it down, say it out loud, figure it out. Be honest and brutal. Are you sitting at work all day? Are you eating poorly? What do you do after work? Do you watch TV, sit, become and office worker at home? Once you have that figured out, focus on what you want and why.

2. Accountable leverage

Think of something which is part of your regular routine that is causing your pain. It could be anything from sitting too much,  standing to much, or simply not exercising. Whatever it is, connect it to the pain you have been experiencing. Connect even more pain to not changing it NOW. Now connect incredible amounts of pleasure and relief to the idea and action of changing NOW!

3. Interrupt your habits

Anytime you find yourself not behaving or slipping back into an old habit, immediately do something outrageous. This could as be silly as plugging your ears and

making a face. Or it could be as insane as jumping up and down, saying “An apple a day keeps the doctor away!” or “movement all day keeps my pain away!”

4.Own your alternative

What’s your alternative? The exercises your doctor gave you? Perhaps it’s simply getting up more often and taking short easy breaks. Whatever it is, do it and link pleasure to it. When you do perform your alternative, reward yourself. A reward may be smiling, calling a friend or playing a game you enjoy.

5. Make it subconsciously automatic

Habits are formed from repetition. The power that makes a habit breaks a habit. Get into the process of being in control of your habits, your movements, and your life. When you learn a new movement or better posture it will feel awkward. Give it time to become normal.

6. Re-test yourself

After a week or two weeks of honest change, re-think about your pain. Are you still in the same spot ? perhaps you are feeling better? Maybe you are even feeling energized and confident! If not, then go back through the process, be brutally honest with yourself and find out what went wrong.

Remember focus on the why not the how. There is no point in bashing yourself over inconsistency, just simply realize the problem and truly commit to changing it by using the steps above.

Patient Motivation-A minimalist approach.

Imagine a cluttered room, furniture everywhere, books that could fill a library, enough dishes to start a restaurant. T.V.s, Radios and other electronics scattered throughout the room, all of these need wires so plenty of them too. All this leaves little room to negotiate, limits behavior and over time causes more stress.

Now imagine the same apartment or house with only the bare essentials or even nothing at all. Its like a breath of fresh air or the ability to even breath at all. Hence the saying, “Minimize to Maximize”.

I have two approaches when riding the McGill slope to improvement. When looked at from a distance they seem quite simple and minimalistic, perhaps that’s why they work for me.

1. Stack and sway
2. Running the option

The Stack and Sway approach is simply selecting the most relevant exercise to address the patients most current needs. Sometimes this maybe just one stretch and one exercise.

Often I will change the word exercise to something else: an example, Movement Therapy or even Movement.

This at times takes great will power but its important to do the minimum required for the maximum amount of change. After the patient begins this simple routine, I begin to add more to the list one at a time. After 2-4 weeks the patient should be into the swing of their routine. Moreover they didn’t have the cramped list that is often handed to them. If there is no room for slip ups and expectations are high, there will be little room for the patient to maneuver. It also leads to higher levels of disappointment between Doctor and patient if (God forbid) there is a slip up.

Running the option requires some preparation on the Doctors part. Just as running the option in football, the client will be able to do the same. The preparation required is to take a list of commonly used rehab exercises and find a suitable option for each. When you prescribe the patient their movements you also give them their option. This places the patient in the driver’s seat. To make or create more control, add in two or three options. This has been a favorite in the past and was developed through personal discussions with a clinical psychologist.

Anyway that you can change the dynamic, empower the patient, and have fun in the process will be a winner in the patients eyes. Rehab doesn’t need to be boring nor does it need to be overly strict. It should be precise, effective, and simple.

SUMMARY

1. Sound yet Minimal efforts help create breathing space for both doctor and Patient.
2. If something isn’t working, it’s much easier to figure out what when your list is small and systematically built.
3. Remember the stigma and emotion attached to words. What do you think when you hear words such as: Pain treatment, Illness, decay, degeneration, exam and problem?

More over what does your Patient think?

Tactile Pain Management: iPhone Application

Over the past few years I have really wanted a way to be more analytical and technological with monitoring my patients outcome assessment. I have tried everything from standard forms and progress reports to mailing out weekly spreadsheets which patients fill in and return. All of these are time-consuming. Ironically enough, often patients lose motivation as well and do not always complete or return forms properly. Through this I began to develop an iPhone application that would allow for reminders and a tactile surface to measure their daily outcomes. I am happy to announce that I used my concept for the first time as a prototype today and am very excited about the potential of the application.

This may serve as a vital tool for simple, cost-effective, and reliable outcome assessment and patient monitoring.  According to the data, outcome assessment should be valid, reliable, responsive to clinical change, and practical.  I believe this application contains these components on a fundamental level.  Most importantly it is practical.  It is simple to administer, requires little input (if any) from the practitioner.  Moreover, it allows for yes/no or quantitative type responses for the user.  Therefore, this application is time and cost efficient as well as valid, reliable, and responsive.

please note these screenshots are from the prototype and are being sharpened up at the moment.

The application will allow the patient/client to monitor the following areas on a daily basis:

1. Pain and Soreness
2. Energy Levels
3. Quality of Sleep
4. Motivation
5. Impact on Others
6. Willingness to Change
7. Productivity
8. Custom Field (Add in anything you would like here; i.e. Job Satisfaction)

The custom field also allows the individual to place a baseline on the lowest and highest values.  For instance, if we use Job Satisfaction as an example, the lowest value may be labeled as “I Hate My Job” and the highest being “I Cant Believe I Get Paid to do This!”.  It will give freedom over the labels allowing the patient to connect better with their questionnaire.

The application then stores the info and begins to chart the data over time.  This is important for a few reasons:

1. It allows the patient to “SEE” their progress.  Any healthcare practitioner can appreciate the impact this has in demonstrating pain trends.
2. It allows the patient to recall and reflect on their treatment over large periods of time in a matter of seconds.
3. It allows the patient to understand flare ups and how even though they may be having a flare up, their overall trend is improving
4. It allows the patient to monitor their own progress and give a sense of accountability

The graphical input will allow the user and practitioner to see the patients progress over the course of:

1. One Week
2. 6 Months
3. 12 Months
4. Year to Date (YTD)

Furthermore, the user is able to enter in reminders so that the alarm on the phone goes off or vibrates during the day to prompt them to do one or more of the following:

1. Record their Levels
2. Do their exercises/stretches
3. Custom Field (Add in anything you would like here)

Because it is important for the patient to have great and effective communication with their personal practitioner(s) I have included a function that allows them to email the charts and data (on the spot) to their practitioner(s).  I am really excited about this because it puts the accountability in the patients hands and empowers them to understand their pain and talk about their pain in a direct and easy manner.

It will also allow the patient to upload their outcomes to Facebook as a way of showing off their improvement (or perhaps lack of).

The update pathway includes:

1. Secure data (no patient names for security) upload to a server for pain management research
2. Children’s version for child cancer patients
3. Graphical Comparison (look at perhaps pain vs mood)
4. Advanced Statistical Analysis
5. Various Graphical Forms

This application will also be able to be branded to your clinic through our brand-the-app affiliate program.  This will allow your clinic to place all branding and information on the app (such as splash screen, about, and contacts) for sales to your patients.  You will also retain royalties from the sales of the app on iTunes or other supplying stores.

In summary, I am VERY excited about the potential of this application as there is hardly anything of its kind currently available.  Its simple, easy to use, and any patient that has an iPhone will love it.  Plus, it makes something that was bland and boring, actually fun.  The potential for research using this application is also very exciting.  This form of outcome measurement is essential in enhancing doctor-patient communication and improving goal setting and decision-making abilities.  Consider this when thinking of this application:

1. Establishes quicker more reliable report with the doctor and patient
2. Unmasks Ineffective Treatments believed to be Effective
3. Improves Goal Setting and Goal Achieving (are we making our goals?)
4. Improves Decision Making
5. Reduces the “burden” of typical paperwork and progress reports
6. Highly responsive
7. Helps justify treatment outcomes to 3rd party providers

I expect this to be available in the iTunes store by the second week of October and for a very affordable price (especially when compared to the cost of a patients office visit).  I hope you share my joy in this application.

If you have any questions feel free to contact me via comments below or through my website: www.anthonyclose.com

Are you a Coach or an Instructor?

Are you a Coach or an Instructor?

Every now and again, you have that one guy; that one guy that’s on a mission to save the world and leave a legacy.  However, more times than not, these guys are fuelled by greed and arrogance.  What is worse?  Perhaps an out of control, caffeine injecting person pumping orders at you?  What is it that makes us cringe at these people? Well it’s definitely not their charisma so I suggest their approach.  Just like a comedian, actor, or even myself writing this blog; a proper delivery is essential to the receiver.  Poor communication is regarded as one of the top errors in business operations.  What is good communication?  Well to answer this I suggest we look at what a coach is and what a leader is.  They both have benefits but as with the delivery, timing is critical to proper usage.

I Consult that Book No One Ever Uses (The Dictionary)

The definition of instructor (coming from the Encarta Dictionary) is someone who teaches something such as a sport or practical skill.  The definition of a coach is someone who trains a person in a specific area, sport, or skill.  Sound similar?  Externally it is.

Internally, it’s much different.  I suggest some lateral thinking at this point.  An instructor is a person who leads through straight answers or direct instruction (hence the name instructor).  They remove the problem by solving it themselves.   A coach, on the other hand, is a person who leads by action and relationship.  I imagine it like this:

1. Instructor: Teacher, Dictator, Politician
2. Coach: Little League, A leader you respect, Anthony Robbins

Now I am not suggesting all coaches are like Anthony Robbins, but you have to admit the guy has a bit of charismatic authority.  What’s most important with a true coach is their ability to make their coaching a life long impact.  This is done through multiple routes but we will find they are all paved with motivation.    Motivation happens over time, Influence doesn’t.  Influence is easy (smile, remember names, listen, and ask questions about them), motivation isn’t but has higher rewards.

Now I ask you, what team are you on?

Here is a quick way to find out.  I adapted this from Jo Owen best of all it’s so easy and effective.

The five O’s of coaching:

Objectives

Overview

Options

Obstacles

If you have a clear view of what you are trying to achieve, consider yourself on the right track.  Let’s speak about spinal pain.  Clear objectives are letting the patient now why they are having the trouble and what a positive outcome would look like (outcome assessment).  The patient isn’t a doctor, that’s why they have you.  During this phase you may take on a slight instructor role (especially with the mechanism of injury part) however, coach them with the outcomes.  They should have a realistic and reassured understanding of the issues at hand.  In my clinic one of the forms we use is the Lower Back Disability Index (Revised Oswestry) to determine initial paper goals.   However, our actual physical goals may vary.  Complex loading tasks with no pain may be the longer term goal but quick improvement in a revised oswestry is reassuring, none the less.  Set short-term outcomes and longer term outcomes with your patients.  Remember to be realistic.  An overly optimistic outcome, if not reached, causes disappointment and a loss of trust.  An overly pessimistic outcome causes negativity which leads to all sorts of downstream problems with recovery.

Overview is about letting them voice their concerns.  In the clinical setting, I want the patient to tell me if they are frustrated, upset, annoyed.  These things are good to get out.  Because we get it out in the open, it will save me major headache in the future if the patient has a mini-meltdown.  Secondly, the patient appreciates your empathy.  They like to know you are genuinely interested and concerned, not only about their spine (for instance) but their mental status as well.  Have them tell you what a reasonable outcome is.  If it’s flawed don’t tell them it’s flawed but suggest a different perspective.

Now that the patient is on track, give them options.  This has application across the board.  From treatment to outcome to follow-up, it doesn’t matter, options rule.  You are more likely to gain compliance by giving options.  When the patient sees two or three ideas and not something you are instructing them to do, the odds are they do it because they choose it. J  My friend Bee Lim who is doing her thesis in positive psychology gave me a brilliant idea.  She said, “Let your patients choose their exercises.”  It was like a huge light bulb when off in my brain.  “Of course” I said, with exclamation.  The next day I started organizing and categorizing my exercises so the patients could choose.  Patients love it.  They love being able to have options.  If they don’t feel like doing the single leg squat, that’s fine, they can do a lunge!  It is so brilliant, simple, and effective.  Even better, it reduces stress on me.  The only option prior to this was the patient not doing it if they didn’t like it.  Now they have another option.

Keeping on track with the patient examples we find ourselves coaching obstacles.  What is going to be an obstacle for the patient?  In the case of lumbar pain, flare ups, is a great obstacle to coach.  Letting the patient understand that flare-ups may occur and are not problematic is important for two reasons.

It reduces their fear and anxiety when it happens

They will be ready to combat it

Reassurance for obstacles is key but what is even more important is prepping the client/patient for the tribulation.  Ask them, “What may stop the flare up from happening?”  Help them prepare for this challenge and you will be delighted with the reward.  For an example, I often find that patients with a simple back ache that is flexion biased, back (glute) bridging is very effective for reducing flare ups.  They only need to do 6-8 repetitions and they feel much better.  Other alternatives are McKenzie stretches, bracing, or the cat-camel.  These are all ideas worth looking into.

How do we know we are still on track?  How do we know if there is anything to correct further or tweak?  Outcome assessment is the key.  I know too many practitioners that do absolutely no outcome assessment.  This scares me.  Outcome assessment should be a summary of progress to date.  After outcome assessment is completed, it is possible to address weak points by starting at objectives and working back through the coaching O’s.

Open or Closed?

Remember when they used to tell you (if you are doctor or trainer from the “old school”) to use a larger ratio of close ended questions?  Times have changed since and the reverse is true.  I assume it will reverse somehow in the future but I personally find an even and meditated mix of open to closed questions works quite well.  Open questions do exactly that, they open the patient’s mouth.  As much as it kills you to listen sometimes (tangents are made quite easily by patients) do it.  You have two ears and one mouth for a reason.   A fatal error to open-ended questions is following the open-ended with a close ended.  This happens more than you think.  Psychologically, it probably happens because we truly don’t want to hear a long-winded answer.  It’s like covering your mouth when someone else is speaking; subliminal body language.  An example:

“Tell me Mr. Smith, how are you feeling today? Are you feeling better?”
“Mr Smith what have you been doing to keep your motivation levels up?  Are you sleeping well?”

Open/Closed don’t do it, end of story

Final Thoughts

Coaching is important and involves the core basics of communication.  Listening, Reflective Listening, and Listening some more.  If you fail to do so you fail to understand why the person you coach is failing.  Sound confusing?  Then you probably need to listen a bit better.  Example: helping motivate a client to understand why they need to change and how you may be of benefit.

Instructing is important at specific times.  There are times when you need to provide clear-cut leadership through instruction.  Example: helping a client understand how to squat (which may be frustrating).

Figure out when to be a coach and when to be an instructor.

Gold Nugget: If you are having trouble listening or seem to space out while someone else is speaking (trust me we all do it) try the following:

1.  When there is a natural pause in the conversation don’t speak (like you want to), paraphrase what they just said back to them.

2.  When they finish talking, ask an open question.  I know for most guys, this is crazy talk but just do it and reap the result.

3.  ”The sweetest word in language is a persons own name”  This is true.  Be involved in them and what they are doing.  Interjecting your own opinion doesn’t get you far.  Even if you do, what did you really change?

Mandatory Reading

How to Lead: 2nd Edition: Jo Owen