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Pain in the Neck | notes from a neck pain clinic I heard some wonderful opening lines waft through the thin cubicle curtains (as if privacy were just a visual thing) in my time as an NHS physiotherapist, but nothing beats the pain of 'Shall we share a story?' - an intrusive frown to boot I bet - delivered by an eager early adopter of the psychosocial aspects of our work, back in the late nineties. But where and how should we begin our sessions - and does it matter? Is it possible that the first words of the session carry greater import than we care to acknowledge? And do our initial muttered utterances have implications for the trajectory of the entire 'therapy'? Roberts and Langridge (2018) have recently noted that surprisingly little attention has been given in the literature on how 'best' to open the clinical encounter, but one study does at least shed some light on the variety and preferred 'openings' that physiotherapists use. Chester et al (2014) audio-recorded 42 initial consultations (and 17 first follow-up encounters - but we won't be discussing those here, interesting though they are) between qualified physiotherapists and individuals with back pain, in an adult musculoskeletal, primary care outpatient setting. Eleven different opening questions were identified which were then used to determine clinicians' preferences in a national survey from a broad range of physiotherapy professional networks (Sports Medicine, Orthopaedics, Massage and Soft Tissue Therapy, and Pain Management). A selection of the openings used by physiotherapists from Chester et al (2014). The preferred opening question for an initial encounter among the physiotherapists who responded was: 'Do you want to just tell me a little bit about your problem first of all?' Although the survey response in this study was small, the paper apparently generated much debate. I don't know about you but some of these opening phrases sit rather awkwardly with me: talk of a 'bit of a chat' and 'a little bit about your problem' are hardly suggestive of a forthcoming expansive discussion. Personally, I tend towards usually opening with a 'so what's the story?' and then sitting in silence until the narrative has run dry, before engaging with the conversation. Doctor and writer John Launer has also discussed openings in his wonderful book 'Narrative-Based Practice in Health and Social Care' (2018). He suggests there is no reason to avoid one of the conventional questions, such as 'How can I help you?' but does counsel against the use of formulations such as 'What's the problem?' arguing that this 'already closes down possibilities - for example there may not be a problem or there may be several'. He also notes that trained mentors and coaches often start meetings with the question: 'What are you hoping to get out of our conversation today?' Asking this can save a lot of time that might otherwise be spent barking up the wrong tree, and the answer is often quite unexpected, he notes (Launer 2014). In another fascinating piece - 'The Three Second Consultation' - Launer (2009) spends over an hour reviewing the first three seconds of a recorded consultation - concluding that the best conversations, whether social or professional, are unconstrained by any prior expectations of where they ought to go. Rita Charon - in her book 'Narrative Based Medicine' - describes using 'tell me what you think I should know about your situation' followed by 'a commitment to listen and not to write or speak'. Charon describes how foregoing the urge to order the narrative leads to her absorbing what is being said without ' deranging the narratives into my own form of story.' She describes listening 'as hard as I can.' Indeed Charon cites work suggesting that warmth and intimacy between clinician and patient tend not to build over time, but achieve whatever level they will achieve at the first meeting. And what do we do after the initial response to our opener? According to Roberts & Langridge (2018) physiotherapists interrupt the patient whilst they are answering the opening question in 60% of cases! Marvel et al (1999) found nearly half of patients were interrupted whilst describing their problem and - wait for it - patients were given on average just 23.1 seconds to describe their problem before being interrupted. But how long does it take a person to describe their problem? Langewitz et al. (2002) reported that people will take on average 92 seconds to explain their problem in an outpatient setting (if they are not interrupted!). Peter O'Sullivan has discussed the benefits of staying silent after his initial opener of 'tell me your story'. He says 'everyone who comes to me has a story. Usually in that first minute you'll hear something really important about their story - if you just don't say anything - and that will lead you down a path.' (Pain Reframed Podcast 2017). So, whatever opener you decide upon - hush and hold thy tongue dear clinician and LISTEN AS HARD AS YOU CAN! References Charon, R 2006 Narrative Medicine: Honoring the Stories of Illness Chester, E.C., Robinson, N.C., Roberts, L.C., 2014. Opening clinical encounters in an adult musculoskeletal setting. Man Ther, 19, 306-10 Langewitz, W., Denz, M., Keller, A., Kiss, A., Rütimann, S., Wössmer, B., 2002. Spontaneous talking time at start of consultation in outpatient clinic: cohort study. , 325 (7366), 682-3. Launer J (2009) 'The Three Second Consultation' Postgrad Med J 2009;85:560 Launer J (2014)'Good Questions' Postgrad Med J 2014;90:121–122 Marvel, M.K., Epstein, R.M., Flowers, K., Beckmanm H.B., 1999. Soliciting the patient's agenda: have we improved? JAMA., 281 (3), 283-7. Pain Reframed Podcast 'Caring Deeply and Dropping Your Ego' Dr. Tim Flynn and Dr. Jeff Moore with Dr. Peter O'Sullivan Roberts, L. and Langridge, N. (2018) Principles of communication and its application to clinical reasoning. In, Petty, N.J. and Barnard, K.(eds.) Principles of musculoskeletal treatment and management: a handbook for therapists: a handbook for therapists. (Physiotherapy Essentials) 3rd ed. Edinburgh. Elsevier, pp. 209-233. If you are interested in learning more about Narrative-Based Practice in Health Care, John Launer and colleagues are running a three day workshop at the University of Hertfordshire, UK in Summer 2019. Further details here: Conversations Inviting Change
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This post contains affiliate links. For more information, click here. Road trips are adventurous, raw, and so intriguing they've inspired movies from It Happened One Night to Thelma & Louise. You have flexibility. You stop when there's something interesting to see or do, or when you just want a break. You stay in one place as long as you want, and you move on to the next one whenever you want. You don't have a plane to catch, and you don't have to be molested to get on board. Your car is your cocoon; you can load it with whatever you're going to want. But the trip isn't about the car; it's about you and the road and where the road takes you and where you choose to follow it, eyes wide and mind open and heart full of excitement. And when you put solo travel and road trip together, it's magic. It's a rare and nurturing oasis of freedom in our over-regulated, over-scheduled, over-intrusive, over-judgmental modern world. It's life on your terms. 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At the end of every driving day, after I checked in to my hotel room and cleaned out the car, I got online to figure out where to stop next and what I'd like to see on the way--a small museum, a historic site, a local park. I made reservations if it looked like rooms were filling up, but the best driving days were the ones when I knew I could go until I wanted to stop. Decide how much you want to drive daily and weekly. I settled on roughly six hours per day, five days per week. I thought this would be a fairly light schedule, especially after years of driving from northern Virginia to my parents' home outside Boston. I've seen some travel bloggers write about driving 12 hours in a day, and great for them if that's what they like. But for me, the point of the journey was the journey, and I wanted to spend more time exploring out of the car than in it. 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Hit snooze. Visualize day ahead.5:24: Alarm goes off again. Get up. Make coffee. Do crunches.5:30ish: Over coffee, go online and make sure nothing catastrophic happened overnight, e.g. the blog didn't get hacked, Trump didn't tweet the nuclear codes, etc.5:55: Don exercise clothes and go outside or to hotel gym to work out.7ish: Shower and dress for the day. Comfy casual clothes for driving. No make-up, just eye cream with sunscreen, tinted moisturizer with sunscreen, lip balm with sunscreen, curled lashes, and body lotion with sunscreen. Keep concealer, powder foundation, red lipstick, and 3-in-1 blush, highlighter, and lip tint at the ready just in case.7:45ish: Protein breakfast, no simple carbs. Grab an apple for lunch.8:15ish: Pack, load car, swap out CDs. Check out of hotel. (Even though most hotels email a receipt, I always ask for a print-out at the desk and look it over before I leave, just in case.) 8:45ish: Hit the road. Stop along the way at an interesting site or two. 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You don't want to return to an untidy home (and you don't want any multi-legged squatters moving in while you're away). I set aside a full day for this. Plan for a short first day of driving. Leaving can be the most stressful part of a trip. Give your extra self time to double-check that you've packed the prescriptions and turned off all the appliances (you can even snap pictures of them if you'll want the reassurance). Make a one-night reservation at an inexpensive highway hotel; just make sure it's far enough away that you won't be tempted to turn home to get that one last thing you wish you'd packed. Prepare to come home. This is part of preparing to leave, so that it won't haunt you near the end of the journey. I brought along a re-entry folder, for some paperwork regarding things I'd need to handle upon my return. Toward the end of the trip, I also planned for a short last day of driving, so that if there were any problems at home, I'd have time and energy to cope with them. I reserved what I hoped would be a luxury hotel room for my last few days on the road, so that I'd be coming home feeling rested and so that the last stretch of the trip wouldn't seem like more of a downer than necessary. Be flexible. You know that plan I had to see five new states? I only got to three of them before I decided that the last two would just be too much for this trip. On the other hand, I visited lots of places that I would never have planned ahead, just because they looked intriguing, from the Museum of Space History in New Mexico to the Grand Ole Opry in Nashville. Go with the road and go with your gut. 2) A Priority on Safety You matter. Your safety matters. Take it seriously. Have your car checked out before you leave. I did this a few weeks early so there'd be time for any necessary repairs. Bring: A navigation system. Make sure your maps are updated.A road atlas. Electronics fail. Books don't. Have a back-up.Coolant, oil, and jumper cables. A road safety kit.A First-Aid kit.A Swiss Army knife. Membership in an auto club.A spare key.Any needed medications. I always travel with Extra-Strength Tylenol for headaches, Advil for muscle aches, and Claritin for allergies. (I'm happy to report that I didn't need the Tylenol.)Your Passport and of course your driver's license, registration, and proof of insurance. Establish your safety rules. It's easy to make wrong decisions in the moment when you don't have firm rules in place. Mine were: Never let the gas tank go below 1/2 west of the Mississippi or 1/4 east.No hiking alone in large parks. Marked trails in small parks were okay. No alcohol until the car is parked for the night. I also had a soft rule of only one glass of wine per night, which I bent twice for craft cocktails. But most nights, the only thing I drank was water. No stopping on the shoulder for photographs, no matter how beautiful the scenery. Stop only at designated overlooks and turn-outs. You might notice a few places in my narratives with metaphoric descriptions of landscapes and no pictures to match; that's why. 3) Lodging that Suits Your Style Lots of travellers are comfortable at hostels and campgrounds. If you're one of them, you might want to skip this part. I prefer luxury hotels, but they're not practical for one-night stops along the road. For road trips, I like a combination of casino, casual-convenient, and extended-stay hotels. Casino Hotels Casino hotels are a great option for women travelling alone, because: They're safe. There are cameras and security personnel everywhere. In casino towns, you can even walk alone at night, because they're all lit up, and there are lots of cops around. They're inexpensive. They're not in business to make money on the rooms, so you can usually stay for cheap or even for free. They usually have reasonably priced or even complementary valet parking. The big ones have rewards credit cards without annual fees, making them a better bet than most travel credit cards, and you also earn points redeemable as cash with their player's cards. There's always something to do. There are restaurants and bars, spas and pools, and of course table games and slot machines. These casino brands have hotels in multiple locations: Caesars Caesars has properties all over the country. Along with its namesake, its brands include Horseshoe, Harrah's, Bally's, and others. Its properties range from luxury to well-at-least-it's-comped. The two nicest hotels where I stayed on my recent road trip were Caesars properties. Its rewards program is Caesars Rewards. MGM MGM is another large network, with properties concentrated in Las Vegas and then scattered primarily through the South and the mid-Atlantic. Most have unique names. They range from luxury to mid-scale. Its rewards program is MLife. Boyd Boyd Gaming has 18 midscale properties in Nevada, the South, and the midwest. Most have unique names. Its rewards program is B Connected. El Dorado El Dorado has 26 midscale properties in the South, the West, and the midwest. Along with its namesake, its affiliated brands include Tropicana, Isle, Lady Luck, and others, with independent rewards programs. As of this writing, El Dorado has announced plans to acquire Caesars next year. Casual-Convenient Hotels These properties tend to be easily accessible from the road. They're often called limited-service hotels, because they lack upscale amenities like spas and bars, valet service, and shopping esplanades. But they do have what long-term road trippers want: big open parking lots, gyms, breakfast in the morning and cookies at night and coffee and tea all day, and usually microwaves and refrigerators in the rooms. My go-to brand has long been Hampton by Hilton, because they're ubiquitous and reliably clean and comfortable and reasonably priced. Hilton's rewards program is HHonors. I did have one nice stay at the Country Inn & Suites by Radisson in Northwood, Iowa. Two big plusses for this brand are cookies all day and a wonderful lending library system whereby road trippers can take a book at one property and return it at the next. Radisson's frequent-travel program is Radisson Rewards. Extended-Stay Hotels For longer stops, I prefer extended-stay hotels. Like their casual-convenient counterparts, they offer complimentary breakfast in the morning and sometimes receptions in the evening. The rooms have fully equipped kitchens with real dishes and glassware, things you miss after weeks on the road. My favorite brand is Residence Inn by Marriott. They're reliably clean and reasonably priced. The gyms and laundry rooms are large and well equipped. The televisions are Netflix-ready for use with your own account. They have a complimentary same-day grocery-shopping service. And there's microwave popcorn in the kitchen, which I never have at home, but can't resist when I'm curling up with a Netflix flick after a long day of driving or writing or laundry or all three. Marriott's rewards program is Bonvoy. 4) Food In my vision for the trip, I thought I'd be alternately dining at local haunts and having happy-hour bites with my single glass of wine at hotel bars. In reality, more often than not, I made myself a small charcuterie board in the hotel room, washed down with water, after I'd finished the tasks on my to-do list. Here's my list of groceries to pack: bottled water half-and-halfcured meats tunacheesesdips cruditesberriesplastic platesplastic cutlerypaper napkinsZiploc bags (more than you think you'll need)a small bottle of dish detergentcold packs 5) A Wardrobe for All Seasons Be prepared for all kinds of weather. After five weeks ranging from hot sun to wet snow (including both in Salt Lake City), here's what I wish I'd packed: Footwear comfortable pumpsversatile, comfy sandalsslip-on sneakershiking bootsrunning shoes flip-flopsslippers8 pr cushy gym socks4 pr ankle socks4 pr thick slouch socks2 pr hose/tights Basics I love Talbots for inexpensive basics that are easy to notch up with the right accessories. 1 comfortable skirt1 pr comfortable cotton pants1 pr designer jeans1 pr mom jeans2 pr cropped pants or Capris3 pr modest shorts4 long-sleeved tops8 short-sleeved tops Dresses 2 day-to-evening dresses3 casual dresses, including at least one that can double as a swim cover-up Outerwear 2 cardigans1 blazer1 windbreaker1 pr winter gloves Hats 3-4 wide-brimmed hats2-3 baseball caps1 warm knit hat Accessories 3 scarves3 belts: wide, medium, thin Activewear 2 pr gym shorts1 pr sweats1 modest bathing suit1 bikini Sleepwear 1 comfy cotton nightgown1 pr cozy pajamas 1 modest silk robe Jewelry I hate worrying about losing my jewelry when I travel, so I bring only a few good pieces that I can wear together: 1 pr comfortable earrings1 simple necklace3 rings3 bracelets1 brooch Laundry Supplies lg mesh laundry bagdetergentbleach podsdryer sheets 6) Bags and Baggage 1 sm. crossbody1 med. crossbody1 lg tote1 duffel bag, for 2-3 days worth of clothes1 lg suitcase, for clothes not presently needed1 picnic basket1 sm. soft-sided cooler that fits inside the picnic basket1 laptop bag1 camera bag packing cubes: Not only do they keep your suitcase organized, but they also help you keep tidy in hotel rooms that inexplicably don't have dressers with drawers. a collapsible wagon: If you take one piece of advice from this whole long post, take this one. I bought my little blue wagon to carry wine-and-cheese picnics to outdoor concerts and the beach. I use it more to lug groceries up to my 11th-storey condo. But it was a lifesaver not only for loading and unloading the car but also for carting the wash to and from hotel laundry rooms. 7) A Fitness Plan You have to be intentional about fitness or it will be too easy to blow off. I resolved before I left to spend an hour exercising every morning before I hit the road, unless I knew I'd be doing significant movement during the day. Most days I either used a treadmill in the hotel gym or went for a long walk in the fresh air. I also did ten crunches every morning while the coffee was brewing and lifted weights once or twice each week. I brought along my favorite work-out DVDs, yoga mat, hand weights, ankle weights, and resistance bands--and didn't take them out of the car once. The good news: I hit my 10,000-step goal every day, and usually far exceeded it, according to my fitbit, and I lost eight pounds. The bad news: It wasn't enough; I lost muscle tone because I didn't do enough strength training. If I'd known then what I know now, here's what I'd do: every morning: 10 crunches and five burpees5-6 times/week: 3-4 miles jogging or brisk walking3-4 times/week: strength training when possible: climb stairs 8) Money Rewards Credit Cards There are a lot of rewards credit cards out there, and it's worth selecting a few that will help maximize what you can reap back from your travels (and put toward your next journey!). Here's the balance that worked for me: 2 cards that pay an unlimited blanket rate of at least 1.5 percent (a go-to card and a back-up). Citibank's Double Cash card pays 1 percent back when you make purchases and 1 percent when you pay your bill; it has no annual fee. 1-2 casino branded cards. Caesars offers a Visa with benefits that include Caesars Rewards Platinum status (the lowest elite tier) for $5,000 in annual spending. It has no annual fee, and even low rollers can get nice rooms comped with it. If your credit is good enough, you may qualify for a Visa Signature, with its additional travel perks, like room upgrades and late check-out. 2-3 cards that pay at least 4 percent cash back for some of your major road-trip expenses. The Discover it Card offers a blanket 1 percent cash back on most items, and 5 percent on quarterly categories, like restaurants and gas stations, on up to $1,500 in purchases. It has no annual fee and will double all the cash back you earn during your first year. Cash Some people don't feel comfortable with a lot of cash; some people only feel comfortable with a lot of cash. Bring the amount you feel comfortable with. Just make sure to carry enough $5s and $1s for tips. And bring quarters for laundry; most hotels can sell you a roll, but I wouldn't count on it. Don't forget your ATM card(s). 9) Electronics and Entertainment Your list will depend somewhat on your personal preferences, but here are my road-trip must-haves: phone and chargers: I like my iPhone SE because it's small but has a good camera.earbuds: I save the ones they give out on planes and use them to catch up with the morning news while I exercise. laptop and charger: The only laptop I want to take on the road is my MacBook Air, because it's thin and light.cameras, chargers, cables, tripod: My big camera is a Nikon D3100 DSLR, which I often use with this tripod. I use my Sony DSC-W70 when lugging a DSLR is impractical; it's lightweight and takes good videos. a variety of things to listen to: I brought around 100 CDs, from classical to Christian (which was great for singing along in praise of God's creation), and swapped them out in the mornings before I hit the road, and I still got bored with them. I would add educational CDs from the Teaching Company and some Rosetta Stone to polish up one of my rusty languages. There are also podcasts and audio books, if you enjoy them. reading material: I like to bring a lot of magazines when I travel, because I can leave them for someone else to enjoy and lighten my load as I go. On the other hand, I usually limit myself to one book, because they're heavy. journal(s)/notebook(s): It's easy to forget things on the road, whether it's how your heart soared seeing a family of deer scamper through the Black Hills or the tour hours at Southfork Ranch. Write them down. I love these notebooks. 10) The Right Mind-Set A solo road trip is a wonderful opportunity, but it can be physically and emotionally grueling. Driving hours a day for weeks is tiring, and there's no one to take the wheel when you want a break. Things will go wrong. You may get lost. I took an hour-long detour through the Mojave Desert in California because I overshot my turn to Laughlin, Nevada. You may get scared. I've developed a weird phobia of overpasses that are so high I can't see the ground. You may get lonely. I missed my late mother, with whom I took my previous cross-country road trips, and I cried from Arizona to New Mexico. You have to set your mind to accept these kinds of things before you go. You have to allow yourself to feel emotional swings without being overwhelmed by them. You have to believe that the rewards are worth the risks. (And if you can't, that's okay, and it's better to realize it; long-term solo road tripping is not for everybody, and there are lots of other ways to travel.) I never questioned. No matter how sad or scared I became, I loved being on the road, and being on my own. And I slept better than I have in years.
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