In all seriousness, if I’d gone to a Physiotherapist every time I had an ache or pain this past year, I would have been having treatment every single week and my bank balance would be a whole lot smaller. Two treatments isn’t an unreasonable number of visits for each ‘episode’, but if that happens every week (which was the case for me), that’s almost $8500 for the year!
Last year I decided I should keep a pain diary for a week. I quit after Day 1. Nine different episodes of pain and focusing on it for a whole day just make me bloody miserable.
If you’re a regular to this page you will have seen and heard that last week I pushed the envelope a couple of times – an unusually big training day last Wednesday really flared up an old and unknown knee issue, and trying out a new exercise on Friday with perhaps a little too much weight for a first attempt; a 36kg ‘windmill’. The knee is still too uncomfortable for me to sit down on the floor with my backside on my feet and knees fully flexed; it feels sore and swollen inside the joint.
Sunday morning I woke with crippling low back pain. I was struggling to stand upright, had several incidents of ‘stabbing’ pain throughout the day which stopped me in my tracks, and I could feel myself excessively bracing most of the time. I struggled to find any position which was comfortable and there were things I couldn’t do with my two kids….but two days later it’s almost as if that never happened.
I have nothing to ‘treat’ unless that’s something to make me feel temporarily better, which I don’t feel is necessary. The pain in my knee is likely due to a mechanical and chemical response to mechanical overload (supraphysiological overload – see FB live video ‘push push push…ouch’) in which case I know it will resolve with time. The only question is how long. I can make an educated guess that it will be within a month. Of course, I would like to be gone *now* and hopefully it will be days instead of weeks. I would also like to be able to hold a handstand for 60 seconds too. The common link between these two wants is time and patience.
On the latest episode of PT Inquest (Jan 18, Ep 97), Erik Meira and JW Matheson discuss a systematic review published Jan 7 in JAMA by Dr Tammy Hoffmann (PhD) and Prof Chris Del Mar, from my old Health Sciences and Medicine faculty here at Bond Uni on the Gold Coast; ‘Clinician’s Expectations of the Benefits and Harms of Treatments, Screening, and Tests: A Systematic Review’.
http://ptpodcast.com/podcasts/pt-inquest/ (also available on iTunes)
Unsurprisingly, clinicians were widely found to over-estimate the benefits of an intervention and under-estimate the risks. This review followed a similar study conducted by the same group in 2015 (according to Erik and JW) which identified that patients also over-estimate the benefits and under-estimate the risks of medical interventions; so we have a double-whammy from both sides of the equation. The net result is people receiving unnecessary interventions and being exposed to unnecessary risks, not to mention the additional costs in time, money and other resources to the health care system.
Erik and JW discuss something very similar occurring in Physiotherapy. Over-servicing is a big issue in our profession (and beyond). Far too often clients are being sold into programs of care they simply don’t need and won’t benefit from.
Here are two apt quotes attributed to Voltaire
“The art of medicine consists of amusing the patient while nature cures the disease.”
“The art of medicine consists of amusing the patient while the body heals itself”.
Scenario 1: “You’ve just strained the tissues in your back Jill. The discomfort you’re experiencing is most likely a response to the tissue not being able to tolerate the load that briefly went through them and potentially a normal chemical inflammatory response. I can’t change that process for you, but there are some things you can do to make yourself feel more comfortable while your body does its’ job healing itself, which it’s obviously already started to do. We can expect that is may take around 3 weeks for the symptoms to fully resolve; it could be a little more, but hopefully it will be quicker than that. If you’re really struggling and you’d like me to try and help you feel more comfortable, I may be able to do that but that’s unlikely to be significantly better than the things you typically find relieving. If you’re not getting sufficient relief on your own, I would be happy to try and help with what I can do, either here in the rooms or with some exercise and activity. As you’re not currently very active Jill, once you’re feeling a little more comfortable, we can certainly help get you moving a little better and feeling stronger and more confident so that this sort of thing is less likely to happen again; how does that sound Jill? ”
Outcome: Single visit. Open invite to return if symptoms don’t resolve as expected through natural history. Jill knows that she can come in for temporary pain relief if she finds that she cannot manage that herself. Jill leaves understanding why she has pain, she has some strategies for active self-management and feels positive about a relatively quick, natural recovery process. She also has an encouraging solution to help her improve her physical resilience and improve overall physical health. We become her guide and interact with her based on sound principles and contemporary best practice.
Scenario 2: Multiple visits++. “You have what’s called discogenic low back pain Jill. It’s likely that one of the discs in your back has a tear in it, perhaps even bulging, like this [show model of budging/tearing disc]. Don’t worry, there are lots of layers to the disc but they generally don’t repair very well if at all so you’ll have to avoid bending and twisting, especially with any form of load. Right now, picking up a heavy weight from off the floor would likely just flare it up or make it worse, so avoid doing anything like that. I recommend we start a rehab program straight away. Initially that will be 3 sessions a week to get on top of your pain, then we’ll move to an exercise program to address the real cause of this which will likely be a weak core and the muscles around your spine not firing properly. I get some really great results with [dry needling, taping, TENS, ultrasound, whatever] and I would expect your symptoms will have fully resolved within 4 weeks. Once we’ve got on top of the pain, we’ll be able to start you on a program of active rehab to strengthen your back [insert choice of exercise programing – clinical pilates?] to make sure this never happens again; how does that sound Jill?”
Outcome: We’ve robbed Jill of her most valuable asset in recovery – self-efficacy. We’ve introduced a real sense of fear of structural damage, created maladaptive believes about potentially harmful movements and activities (nocebo), focused on harm and not distinguished that from hurt, triggered hypervigilant behaviour likely to be counterproductive to a normal recovery, recommended unsupported passive treatments which provide no benefit, and created dependence upon us to improve her health.
I am passionate about this because as a new-grad Physiotherapist who didn’t know any better (not that long ago), I was following Scenario 2 with every patient. Now I look at what I was doing and see it not only as poor practice but quite frankly unethical.
I’m more than happy now not to re-book someone if I’m pretty certain that they’re going to get better of their own accord. It’s not good for our bottom line to have someone attend only once instead of twelve times or more. Consumers of Physiotherapy should feel that they can trust that their therapist is providing them the evidence-based care they *need* and not feel that they’re paying for services that we know are not helpful or based on outdated practices.
I will not over-service the people who seek and need my help or recommend a course of treatment which I know to be no better than just waiting and being patient.
I will not be known as the “used car salesman of Physiotherapy”.