Andre Agassi on his Back Pain

Tiger Woods’ remarks about his back pain spawned a rumble in the physio community. This piece by Peter O’Sullivan sums things up nicely. My favorite thing about Peter’s write-up is that it’s aimed at health care providers, not the athlete. Tiger’s latest injury involves his right wrist:

Keeping with the theme of athletes and their bodies, check out the following excerpts from Andre Agassi’s autobiography, Open, describing his experience with back pain. It’s a great first person’s view on the relationship between back pain and emotions.

Now rising from the center of the fatigue comes the first wave of pain. I grab my back. It grabs me. I feel as if someone snuck in during the night and attached one of those anti-theft steering wheel locks to my spine. How can I play the U.S. Open with the Club on my spine?

I was born with a spondylolisthesis, meaning a bottom vertebrae that parted from the other vertebrae, struck out on its own, rebelled. (It’s the main reason for my pigeon-toed walk.) With this one vertebra out of sync, there’s less room for the nerves inside the column of my spine, and with the slightest movement the nerves feel that much more crowded. Throw in two herniated discs and a bone that won’t stop growing in a futile effort to protect the damaged area, and those nerves start to feel downright catastrophic. When the nerves protest their cramped quarters, when they send out distress signals, a pain runs up and down my leg that makes me suck in my breath and speak in tongues. At such moments the only relief is to lie down and wait. Sometimes, however, the moment arrives in the middle of the match. Then the only remedy is to alter my game – swing differently, run differently, do everything differently. That’s when my muscles spasm. Everyone avoids change; muscles can’t abide it. Told to change, my muscles join the spinal rebellion, and soon my whole body is at war with itself.

The cortosine injection:

I stretched out on the table, face down, and the nurse yanked down my shorts. The doctor said he needed to get his seven-inch needle as close to the inflamed nerves as possible. But he couldn’t enter directly, because my herniated disc and bone spur were blocking the path. His attempts to circumvent them, to break the Club, sent me through the roof. First he inserted the needle. Then he positioned a big machine over my back to see how close the needle was to the nerves. He needed to get that needle almost flush against the nerves, he said, without actually touching. If it were to touch the nerves, even if it were to only nick the nerves, the pain would ruin me for the tournament. It could also be life-changing. In and out and around, he maneuvered the needle, until my eyes filled with water.

Finally he hit the spot. Bull’s-eye, he said.

In went the cortisone. The burning sensation made me bite my lip. Then came the pressure. I felt infused, embalmed. The tiny space in my spine where the nerves are housed began to feel vacuum packed. The pressure built until I thought my back would burst.

Pressure is how you know everything’s working, the doctor said.

Words to live by, Doc.

Soon the pain felt wonderful, almost sweet, because it was the kind that you can tell precedes relief. But maybe all pain is like that.

Perception of our bodies, pains, and injuries can have stunningly strong effects on our daily function.

Andre Agassi’s book is the first autobiography I’ve read cover to cover. And, it’s one I’ll be re-reading over & over. Pick it up here.

@Cinema_Air

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Efficient Communication Saves Lives…

While many medical professionals spend their days juggling patients and insurance companies (and more!), they are also expected to keep up with the latest research. Research that might save lives and improve quality of lives are obviously important, but what about the integration of new or novel data?

Change in the medical world takes years. Possibly decades. This passage from Atul Gawande’s The Checklist Manifesto speaks to the difficulty and delay in adoption of new or novel data derived from research:

     Sometimes, though, failures are investigated. We learn better ways of doing things. And then what happens? Well, the findings might turn up in a course or seminar, or they might make it into a professional journal or a textbook. In ideal circumstances, we issue some inch-thick set of guidelines or a declaration of standards. But getting the word out is far from assured, and incorporating the changes often takes years.

One Study in medicine, for example, examined the aftermath of nine different major treatment discoveries such as the finding that the pneumococus vaccine protects not only children but also adults from respiratory infections, one of our most common killers. On average, the study reported, it took doctors SEVENTEEN YEARS to adopt the new treatments for at least half of American patients.

What experts like Dan Boorman have recognized is that the reason for the delay is not usually laziness or unwillingness. The reason is more often that the necessary knowledge has not been translated into a simple, usable, and systematic form. If the only thing people did in aviation was issue dense, pages-long bulletins for every new finding that might affect the safe operation of airplanes – well, it would be like subjecting pilots to the same data deluge of almost 700,000 medical journal articles per year that clinicians must contend with. The information would be unmanageable.

(Emphasis mine)

While we cannot deny the importance of medical research, it is just as (maybe even more) important that the information is structured into an actionable architecture for efficient practicality.

@Cinema_Air

The Inside-Outside View to Better Decision-making

Decision-making isn’t always the easiest thing in the world. While many errors may seem obvious in hindsight, they’re rarely as crystal clear during the decision-making process. Even worse, we have a tough time imagining the opposing view. As Michael Mauboussin states in his book Think Twice, we have “a tendency to favor the inside view over the outside view.” He goes on to explain,

An inside view considers a problem by focusing on the specific task and by using information that is close at hand, and makes predictions based on that narrow and uniques set of inputs. These inputs may include anecdotal evidence and fallacious perceptions. This is the approach that most people use in building models of the future and is indeed common for all forms of planning.

Compare that with The Outside View:

The outside view asks if there are similar situations that can provide a statistical basis for making a decision. Rather than seeing a problem as unique, the outside view wants to know if others have faced comparable problems and, if so, what happened. The outside view is an unnatural way to think, precisely because it forces people to set aside all the cherished information they have gathered…. The outside view can often create a very valuable reality check for decision makers.

He goes on to list three illusions that lead one to the inside view: the Illusion of Superiority (I’m better than them), the Illusion of Optimism (that’ll never happen to me), and the Illusion of Control (I can make this happen). Obvious question: “How can we get better at adopting The Outside View?”

Mauboussin pulls from Kahneman and Tversky, and distills their 5 step process into 4 steps.

  1. Select a reference class: “Find a group of situations, or a reference class, that is broad enough to be statistically significant but narrow enough to be useful in analyzing the decision that you face. The task is generally as much art as science, and is certainly trickier for problems that few people have dealt with before. But for decisions that are common – even if they are not common for you – identifying a reference class is straightforward.”
  2. Assess the distribution of outcomes: “Once you have a reference class, take a close look at the rate of success and failure…. Two other issues worth mentioning. The statistical rate of success and failure must be reasonably stable over time for a reference class to be valid. If the properties of the system change, drawing inference from past data can be misleading…. Also keep an eye out for systems where small perturbations can lead to large-scale change. Since cause and effect are difficult to pin down in these systems, drawing on past experiences is more difficult.”
  3. Make a prediction: “With the data from your reference class in had, including an awareness of the distribution of outcomes, you are in a position to make a forecast. The idea is to estimate you chances of success and failure…. Sometimes when you find the right reference class, you can see the success rate is not very high. So to improve your chance of success, you have to do something different that everyone else.”
  4. Assess the reliability of your prediction and fine-tune: “How good we are at making decisions depends  a great deal on what we are trying to predict. Weather forecasters, for instance, do a pretty good job of predicting what the temperature will be tomorrow. Book publishers, on the other hand, are poor at picking winners, with the exception of those books from a handful of best-selling authors. The worse the record of successful prediction is, the more you should adjust your prediction toward the mean (or other relevant statistical measure). When cause and effect is clear, you can have more confidence in your forecast.”

The more probabilistic the context, the better these step will work. Now you know how to take The Outside View to increase the odds of a better decision.

The main lesson from the inside-outside view is that while decision makers tend to dwell on uniqueness, the best decisions often derive from sameness. – Mauboussin

— @Cinema_Air

LeeAnne K-G: Top 5 Life lessons Learned So Far

I recently asked LeeAnne Ketchen-Gullett, ATC, MS about her “Top 5 Life Lessons So Far” and she was generous to respond with this fantastic guest blog. It is a worthwhile read that I will definitely re-visit periodically. In case you haven’t already met LeeAnne, you can find her on twitter @LKetchen14ATC (not only is she a Certified Athletic Trainer, but she’s also a Full-time Volunteer!). Enjoy the read and I hope you get as much out of it as I do.


There is Value to Each Individual You Meet

Meeting new people is one of my favorite things whether it is on a plane, conference, sports event,  work related or standing in a line. I take it as an opportunity to understand people and myself. I am not saying I “like” or have great experiences with every person I meet but I do take something away from each individual and interaction and carry it with me. During good or bad interaction I learn how to listen, engage in intellectual conversation, know when not to speak, and use of body language.  I’ll admit, often I have learned communicating the hard way but its valuable the next time a similar situation presents itself. I have met amazing people in unique circumstances and they have made an impact on me forever and may or may not even realize it. The world is big and full of incredible people. I would like to meet as many people as possible for the experience and to take a little bit of them with me. I find great importance to live in the moment and take the opportunity for person interaction because everyone has their own story and we can all learn from one another. That being said- even the smallest interactions can play a role, never underestimate the impact you can have on someone else’s life.

The world owes you nothing

Just because bad things happen doesn’t mean something good will happen to make up for it. Just because you work your tail off may not mean you get the job you want or put you necessarily where you want to be. I have learned to not “expect” much in return for what I do or accomplish. It is about changing your mindset and attitude. I work and am there for people because I love to do it and the reward is it makes me feel good. It is about being a good person and waking up with a positive attitude. I find that if I can do that then it will trump many things. It is important to focus on what we do have control over and the goals we set for our self. It is not okay to expect rewards for all things we do because we feel that we “deserve” it. It doesn’t always workout that way and we must carry on, work hard, and move forward. In life nothing is ever guaranteed, so everyday create your own luck and opportunity.

You cant wait for the perfect opportunity- Take a chance and step out of your comfort zone

Looking back I feel like I missed out on some opportunities because I was waiting for the perfect “moment” or “timing” where everything would fall together nicely and work out perfectly. What I’ve learned: rarely does this happen. I discovered that I wasn’t good at having a plan. I just ruined plans. However, I was better at planning and found it to be more efficient in accomplishments. If you take a chance and go with a positive attitude, it WILL work out and you will find success. I used to be scared that something bad would happen and it would mean a big set back in my life. I was wrong. It was in the moments where I didn’t have a plan, that potential opportunities opened up, when I dove in fully. I had no idea how things were going to turn out or where it was going to lead me, but it is in those moments I learned the most. Being in uncomfortable situations uncovered feelings I didn’t know I had and didn’t know I could handle. It’s about discovering parts of yourself you didn’t know existed and using them for future situations. This has happened to me on more than one occasion and I couldn’t be more grateful for chances that I have taken on a whim. It has lead me down a strong path of meeting amazing people and being put in tough situations that has built me as a person and professional.

Show that you care, be present

I believe that we are all connected somehow and this kind of goes hand in hand with my lesson number one.  I have found that building trust, being passionate, being considerate and caring can be the most rewarding thing one can do.  I didn’t understand this until I started getting e-mails and cards from people expressing gratitude about how important it was to them that I gave them time, listened to them, and show that I care. I truly value each person I work and interact with. It has to do with being a good person, doing the right thing, and being there for someone because you want to be genuine, to be their listening ear, and show concern. When I get feedback (cards and emails), I realize how much their feedback affects me, and I then understand the impact I may have on others. That is what feels amazing.  I think it is so important to not only show that your care, but when given the opportunity, let others know that you appreciate them. Even if it is as simple as a solid “thank you”, I know in my industry it can go a long way.

“I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” ― Maya Angelou

Intuition and instinct can go a long way.

I think it is important to be in tune with our instinctive nature and follow the path it leads us down. Intuition and instinct isn’t measurable, it’s a feeling and belief based around experiences and facts that have been in our life. These experiences turn into our ability to problem solve and respond to situations for success. I suppose I can take the top four life lessons already mentioned and say intuition and instinct play a huge role in all of them. I would like to think growing up I have had a solid foundation built around strong morals and beliefs. As I get older and go through new experiences and challenges, I find self-talk and reflection to be one of the most beneficial parts to my day. Trusting my intuitive nature and making quick decisions has led me down an amazing journey.

Accept no ones definition of yourself because no one knows you better than you do. Society, parents, teachers may have an image about how you need to be and how to live your life in order to be successful. Fact of the matter is that everyone reacts and responds to situations differently. Life is here for us to create and define our self as a person, how we want to be and what path we choose. It is important to spend life on your own terms and what you believe in.  This is created by the choices we make and not the choices people think we should make. Be you, listen to yourself, and create yourself based on your intuition and instinct. I look forward to each morning, excited to create new opportunity and another day to build a better version of myself.

Connect with LeeAnne Ketchen-Gullett, ATC, MS on Twitter.

And find me @Cinema_Air

“Regret Minimization Framework” by Jeff Bezos

Making major life-altering decisions is inherently daunting. Jeff Bezos, Amazon’s founder and CEO, provides a brilliant filter that simplifies the decision – A “Regret Minimization Framework.” (video at bottom of post) This is simply beautiful:

I went to my boss and said to him, “You know, I’m going to go do this crazy thing and I’m going to start this company selling books online.” This was something that I had already been talking to him about in a sort of more general context, but then he said, “Let’s go on a walk.” And, we went on a two hour walk in Central Park in New York City and the conclusion of that was this. He said, “You know, this actually sounds like a really good idea to me, but it sounds like it would be a better idea for somebody who didn’t already have a good job.” He convinced me to think about it for 48 hours before making a final decision.

So, I went away and was trying to find the right framework in which to make that kind of big decision. I had already talked to my wife about this, and she was very supportive and said, “Look, you know you can count me in 100 percent, whatever you want to do.” It’s true she had married this fairly stable guy in a stable career path, and now he wanted to go do this crazy thing, but she was 100 percent supportive. So, it really was a decision that I had to make for myself, and the framework I found which made the decision incredibly easy was what I called — which only a nerd would call — a “regret minimization framework.”

So, I wanted to project myself forward to age 80 and say, “Okay, now I’m looking back on my life. I want to have minimized the number of regrets I have.” I knew that when I was 80 I was not going to regret having tried this. I was not going to regret trying to participate in this thing called the Internet that I thought was going to be a really big deal. I knew that if I failed I wouldn’t regret that, but I knew the one thing I might regret is not ever having tried. I knew that that would haunt me every day, and so, when I thought about it that way it was an incredibly easy decision. And, I think that’s very good.

If you can project yourself out to age 80 and sort of think, “What will I think at that time?” it gets you away from some of the daily pieces of confusion. You know, I left this Wall Street firm in the middle of the year. When you do that, you walk away from your annual bonus. That’s the kind of thing that in the short-term can confuse you, but if you think about the long-term then you can really make good life decisions that you won’t regret later.

Sources: Academy of Acheivement and Bijan Sabet

Find me on Twitter @Cinema_Air

How to get Lucky

All of us smile back when Lady Fortuna smiles at us. The question is how do we win her smile more often. How do we get lucky?

Richard Wiseman undertook a scientific exploration of Luck in his book The Luck Factor. According to Prof. Wiseman everyone can improve their luck by applying his four basic principles for generating good fortune:

1. Creating and noticing chance opportunities. Mr. Wiseman describes his experiment:

I gave both lucky and unlucky people a news- paper, and asked them to look through it and tell me how many photographs were inside. On average, the unlucky people took about two minutes to count the photographs whereas the lucky people took just seconds. Why? Because the second page of the newspaper contained the message “Stop counting – There are 43 photographs in this newspaper.” This message took up half of the page and was written in type that was over two inches high. It was staring everyone straight in the face, but the unlucky people tended to miss it and the lucky people tended to spot it. Just for fun, I placed a second large message half way through the newspaper. This one announced: “Stop counting, tell the experimenter you have seen this and win $250.” Again, the unlucky people missed the opportunity because they were still too

… lucky participants went to considerable lengths to introduce variety and change into their lives.

2. Listening to your intuition – Exercise your curiosity and find out where it might lead. The journey and/or destination could be just what you need.

3. Create self-fulfilling prophesies via positive expectations – beneficial effect of positive expectations have been widely studied. Click here for scholarly studies and articles.

4. Adopt a resilient attitude that transforms bad luck into good.

Lucky people tend to imagine spontaneously how the bad luck they encounter could have been worse and, in doing so, they feel much better about themselves and their lives. This, in turn, helps keep their expectations about the future high, and, increases the likelihood of them continuing to live a lucky life.

We can all use a little good fortune in our business and personal lives. With Prof. Wiseman’s help we might just get lucky.

You are now equipped to make your own luck; so stop waiting and start doing. Good Luck!

Source: The Luck Factor by Richard Wiseman [pdf]

Follow me on Twitter @Cinema_Air

The Ikea Effect Applied to Physical Therapy

Perception is an all-too-powerful daily catalyst in our lives. It often operates on a subconscious level facilitating decisions and perspectives that quickly and efficiently leverage levels of happiness and satisfaction. The Ikea Effect describes one of these levers.

So what is The Ikea Effect? Norton, Mochon, and Ariely’s research paper define it as “the increase in valuation of self-made products.” It’s the satisfaction and feeling of acheivement one experiences upon successfully assembling an “assembly-required” Ikea product – chair, table, bed, sofa, etc. Time and effort is invested in hopes of assembling (read “producing”) something of value. According to Norton, et al

labor increases valuation of completed products not just for consumers who profess an interest in “do-it-yourself” projects, but even for those who are relatively uninterested

In terms of Physical Therapy, our “product” is restoration of optimum patient function. The Ikea Effect parlays into physical therapy by highlighting the importance of Active Patient Participation. This concept of Active Patient Participation may be easily lifted from other seemingly unrelated fields. Again, from Norton, et al:

When instant cake mixes were introduced in the 1950’s as part of a broader trend to simplify the life of the American housewife by minimizing manual labor, housewives were initially resistant: The mixes made cooking too easy, making their labor and skill seem undervalued. As a result, manufacturers changed the recipe to require adding an egg; while there are likely several reasons why this change led to greater subsequent adoption, infusing the task with labor appeared to be a crucial ingredient (Shapiro 2004). Similarly, Build-a-Bear offers people the “opportunity” to construct their own teddy bears, charging customers a premium even as they foist assembly costs onto them, while farmers offer “haycations,” in which consumers must harvest the food they eat during their stay on a farm.

Active Patient Participation brews a sense of “ownership” that not only encourages patient responsibility and engagement, but also fosters a sense of empowerment that enhances the value of your service. You are now more than a commodity selling on price, you are a resource based on perceived vested value, via the Ikea Effect.

We value what we build. The link between labor and a sense of well-being and value is both intuitive and abundantly recognized. Move beyond passive “traditional” approaches; merge the Science of Evidence-Based Practice with the Art of Patient Perception. Encourage Active Patient Participation in their rehabilitation (and your practice) to build a sense of ownership through you.

Leverage the Love of Labor to transform and enhance your Labor of Love.

“When you sell on price, you are a commodity. When you sell on value, you are a resource.” – @BobBurg

Sources: The Ikea Effect: When Labor Leads to Love[pdf] by Norton, Mochon, and Ariely.

Follow me on Twitter @Cinema_Air