A KISS for Valentine's Day: Keeping It Simple...Sort of

Everything should be made as simple as possible, but not simpler -- Albert Einstein

We've all heard of KISS, No, not the rock band that grew to fame in the 80's. I'm talking about the phrase "Keep It Simple, S....(insert your word of choice)" Within our profession, there has been a propensity to make things more complex than necessary Why is that? There are several possible explanations. I heard Greg Lehman (@GregLehman) make an interesting observation while on the Chews Health Podcast (@TPMpodcast) and more recently the NAF Podcast with Adam Meakins (@AdamMeakins): "There are a lot of smart people in the profession. It's hard to get in [to school] and you work really hard and I think there's a desire to do something that's complex because simple makes it seem that anybody can do it."

That does make a lot of sense. However, do patients want what's simple? Ideally, I think so, but I so know that if we each reflect upon our own clinical practice, we'll probably find several examples of a strange balance between the simple and complex.

Early in my career I ran into a situation that illustrates why I think phyios struggle when it comes to keeping things simple. The patient was a middle aged female that would have been every McKenzie MDT instructor's dream demo subject. She had low back pain with radiating pain into the right leg. Symptoms peripheralized with flexion and centralized with extension. I sent her home with prone press-ups as her primary exercise with standing repeated extension for her to do during the work day. I saw her for a second visit and she was already significantly better. We continued with press-ups without any force progression as that was all that was necessary to centralize/abolish symptoms. She demonstrated improved lumbar flexion motion on re-assessment without production of low back or leg symptoms. I had planned to continue and gradually reintroduce flexion in a future treatment as long as it was indicated, but she never came back. When I called two weeks later to follow-up, the discussion that followed was not anticipated.

"You didn't do anything" was the response I received when I inquired as to why she had not followed-up with her appointment. (Remember, this was very early in my career when my patient interaction skills were still quite lacking! But I remember the conversation almost verbatim) "What do you mean?" was my reply.

"I was expecting a massage or something more." So there we go-- lesson one, establish/understand expectations.

"Are you having any back or leg pain now?" I asked. "No." "So, you're better?" "Yes." "Then I don't understand; how is that you say I didn't do anything?" "Because all I did was that simple exercise that I could have done by myself!" And there it is.

"But you didn't come up with it by yourself, did you? You came to me and I determined that was a good movement for you to do. I could do that other stuff, but I didn't think it was going to be as beneficial for you." Silence. And then, "Well, I was expecting something different." I don't remember exactly how the conversation ended, but you get the idea.

While that very well may have been an example of how NOT to perform a follow-up patient interaction, the point there highlights what some physios do fear with regards to simplicity. However, there are times when patients do gravitate towards simple, as in the explanation by physicians for the reason for their back/leg pain as a "pinched nerve." We know that's rarely what actually is happening and the true reason is often more complex.

Simple with exercise is usually good. Most patients will struggle with movements/exercise with too much complexity. Even if it's the "best" exercise, if they do not do it, it's not very effective. However, something as simple as a Farmer's carry is met with skepticism. "What is this supposed to do?" I'll get asked. "Why don't you go walk to the end of the room and back and when you get back you tell me what you feel?" What can I say, I'm a smart-ass.

via Dr. Andrew Rothschild, DPT, FAAOMPT
Lead Instructor: Modern Patient Education
Mentor: Modern Rehab Mastery
@spear_physio

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