Saturday, May 20, 2023

Leonard's view of the future of rehab

Here is Leonard's website.

I have only just started to examine/ingest it. There is so much there, and like eating feels at my age (72) it's best done in small meals spaced out. 

Right on page 1, we see the project all laid out. Kind of breathtaking really. 

It'll take me quite a while to wade through each of these ideas and fully comprehend how they connect and how far back they go and who all the people were and what they showed about themselves and what they hid from history. 
It's a very big site. There is much to read and ponder through. It's sort of like wandering through a new world, worldview

But let's just start with the video and some highlights from it. (I made notes.)

Leonard's intro
(I love how he starts out, bright and bold:) 

 “Today we speak of embracing a new era of rehabilitation, or what we like to consider, the journey toward human rehabilitation.” 

(Psst: It's for everyone who deals with the entity known as a human. And who wants a better way to do so. Be you an analytic type or a humanist or both combined. You are human also, and you just may want to level up yourself.)

He points out that it's for any/all allied health professionals. That he's able and willing to mentor any professional from any profession:   

"The reality is this might come off a little bit more clearly to physical therapists, OTs, and speech therapists, but this was designed for professionals across all disciplines in medical allied health, mental health, behavioural health, fitness and wellness industries in mind."

He talks about "functional understanding" which we can get to later. There's a heap of stuff about that in the "whitepaper" (I don't know why public papers were ever designated as "white," but I do not want to get sidetracked here). The whitepaper is free to read by signing in on his website

"... the HRF is an open source project."

... Which means, he hopes it will travel by itself through interested parties out into the wider world. 

The situation we face/rehab faces

This is the situation we find ourselves in as professionals in a profession which looks like chaos, faced by people coming for treatment who are told all sorts of contradictory things by different people, left with no way to make sense of it except what they are told, feel left out of the process with their personal experience invalidated, with no way to make sense of any of it, their problem stuffed into some grouping or other that was designated by someone else a long time ago or maybe a week ago, and varies by profession. I would call it a tyranny of nouns and operations that were designed to manage all the nouns, but not the actual people themselves. Huge boundary problems resulting from science that framed us as professionals wrong from the start. But I digress.      

He talks about the biomedical model: 

"...what we have to embrace first off is that you know, we live in this biomedical model, and this model has a number of achievements but it certainly has a number of shortcomings especially when it comes to dealing with health. So where did it start? Well it was this focus on biology exclusively and its become again our dominant model for healthcare. It gained its prominence in the 1800s and has saved a lot of lives. I mean if we think about what it’s done for infection and disease, many more people are living today than in the past because of advancements in the biomedical model. But as we’ve learned, when it comes to health and well-being, it’s been falling short quite significantly. So these significant shortfalls include this excessive reliance on interventions that are targeting biology in isolation, separation of the psychological and social factors from the biological aspects; this idea that somehow they can be separated really is quite illogical and unscientific on so many levels. It really overlooks the true complexity of human health and well-being."

Enter the biopsychosocial model from Engels 1977. He explains the BPS model has certain shortcomings and drawbacks. And that he would like to improve it. Make advancement. He says taking a functional contextualist worldview and treating humans from its standpoint would work better. How? 

"It embraces human complexity. It comprehensively appreciates the history and context of the person and considers each person’s uniqueness and ability to change as a part of the bigger picture. What we really appreciate about this kind of functional contextualistic worldview is that it sees humans as having infinite potential to successfully make things work with whatever problem they face. We believe that’s a really helpful lens if we’re going to be dealing with complexity and we’re going to be dealing with problems that are human in nature. We propose that we need to transition from fixing machines to working with humans, which means we have to develop approaches that highlight human resilience and adaptability rather than treating them as machines that wear down and break down and have to be repaired and you know things can be permanent and unchangeable. In this process, we have to emphasize the dynamic, multi-level, multi-dimensional nature of human challenges as well as what that means for their potential for growth. We also need to acknowledge that people can learn and adapt even while they are in the middle of a health crisis or struggle. In doing so and in concentrating on supporting the individual where they are and working with their health issues, rather than merely trying, attempting to “fix” them, we truly believe we have the potential to make a much greater impact on human health and wellness as a whole."

Sounds good to me, I'm in. 
He talks a bit about how what works better is to stick with a beginner mind, process-oriented, N=1 approach with every single person who comes into the clinic. And it makes sense because each human is a world unto their own self. And he says, importantly... 

"Processes of change are independent from the treatment methods themselves."  

This fits with everything I've read that says that it's not about having some magic method, it's about relating. He introduces the names of the pioneer psych researchers who have developed this new worldview and who have informed his vision so valuably. He says they looked at their own profession, found 600 different ways of going about their business,  and developed an overarching meta-framework with 6 dimensions, called the Extended Evolutionary MetaModel, or EEMM, to which he added (with their support and encouragement) 3 more dimensions to cover return to human physical wellbeing. I really like that two-thirds of this work was already in place already. 👍
He says, around minute 13, 

“What we have found is that by partaking in this journey along with the psychological pioneers, we already are able to speak across the psychological discipline and domain and our hope is by adhering early on to a kind of unified language for process-based thinking that we’re going to truly be able to embrace a transdisciplinary approach to care.”

How does this process approach work? Well, helping people get to psychological flexibility is the goal, really. Not just for the clients, but for the clinicians too. Network theory can provide a tool to navigate complex processes. It can be applied to rehab, can give a picture of interconnected processes within each individual. He has some numbers to share.

  1. over 84% of our client base are high complexity cases which means they have at least three factors or comorbidities. They have a central senseitization inventory that is at least 30 points. Their history and their psychosocial and social determinants of health clearly indicate that they are stuggling and this is a more complex case. 
  2. Over 25% of our patients utilize Medicaid. 

  3. Over 40% of our auto and workman’s comp cases are in active litigation. 

"So, needless to say if you’re looking for a challenging environment to test something, we have that." 

He gives a little rundown of results so far from 250 clients. 

"With HRF, trans-diagnostic FX include: 

  • Psychological flexibility improved 15%

  • Mental health quality of life up by 5%

  • Client satisfaction: 99% - clients feel validated and heard 97%,  and confident 92%."

He's going to be publishing his work with (by the sound of it) some new statistical tools the psych people are coming up with. 

He talks about the financial implications for clinics, always a hot topic, especially for big corporate clinics: 

"The national average rehab cancellation rate for low complexity : 12-25% 

Pain speciality >30%

No show rate ~10% 

For HRF: cancellation rate 7-15%, 1-2% no show rate."

 He talks about "transdiagnostic and social outcomes of learning psychological flexibility skills."

  • "Clients come off opioids, reduce overall medicating, reduce imaging, cancel surgeries.

  • Come off disability and start meaningful careers

  • Parents teach these skills to their kids

  • Spouses and caregivers learn the skills

  • Teachers and professors add it to their curriculum

  • Clients use the skills to go to substance abuse and eating disorder rehab"  

I gotta say, all this seems pretty impressive to me. And I had not dug into the white paper yet. So, there will be more to come. Before I forget, here is the improved website where all my stuff has been given sanctuary by HRF. 😊


Friday, May 19, 2023

Back again


So, I left off writing thoughts here a couple years ago.  I had accepted being newly retired, for real. Had landed that particular plane. Still had runway left. 

I had accepted that I was retired, and deliberately wasn't going to worry about physiotherapy anymore. I was going to edge away from it. Not put any more energy into trying to help it improve. I pivoted. 

I had committed to scouting around on youtube to find things that were interesting. Something I could deep dive into and luxuriate in learning, ponder from all angles, watch develop. 

I settled on Ukraine. It wasn't hard. I mean, there is a war happening there because Russia decided it had the right to believe its own BS and invade its neighbour after having signed treaties, twice, agreeing to borders established between the two countries way back in 1992 or whenever. So, it was as good a way for me to pass the time as any and was very attention-attracting, served to keep me interested in the world, the whirled world. Which is also a verb, not a noun.  

I committed myself to Timothy Synder's excellent Yale education series, The Making of Modern Ukraine. I watched every single class all last fall as soon as it was uploaded. Then I started all over again, and am up to Class 16 of 23. It's a full semester of history. Timothy Snyder is a great teacher, and I take copious notes, but that's not what this particular blog post is all about. 


An email came along one day last month from the Weebly people who had offered free websites and from whom I had built two, one for my former physio practice and another for Dermoneuromodulating. I had let go of the practice site already and decided I would let go of the DNM site too because it was no longer going to be hosted by Weebly for free. They were going to start wanting to be paid. Why keep it? I was no longer teaching. I let people in the DNM Facebook group know that soon it would be gone, along with the very incomplete international directory I had been maintaining there for people who had taken the workshop and wanted a listing. I announced to the Facebook group members that they could grab whatever they wanted from it before it went dark. 

A few people salvaged it, and one guy in particular volunteered to maintain it all on his own site! I agreed, because he gave me a look at the content, all beautifully and functionally reformatted,  and offered to maintain and update the directory and everything, so how could I say no? And I turned over the url to him because he offered to pay for it, off into the distant future. It was like he was carefully lifting an albatross from my neck so I could retire even more! I asked him why he wanted to do me such a service and he said because it lined up well with his own vision for the profession, Dynamic Principles, and his Human Rehabilitation Framework. Here is his introductory video, Clinical Overview of the Human Rehabilitation Framework (HRF).

We talked. 
The more I learned about Leonard Van Gelder and his company the more it started to feel like home there! This is a screenshot of the principles he has, and I agree with them all. 

So, I'll be blogging more about this. It's all quite wonderful, and I feel very congruent with it all, and I'm not promoting Leonard just because he was kind enough to take responsibility off me by hosting accumulated DNM content, I'm promoting both him and his mission because it's like the freshest air I've ever had the privilege of breathing when it comes to physiotherapy. If the profession manages to change and save itself from becoming a dinosaur, it will be thanks to his vision, I'm pretty sure.  

Next post: Leonard's vision for evolving rehab science.