I recently shared the heart-breaking story of the untimely passing of Talia Goldenberg here following elective surgery to fuse her neck. The article published in The Seattle Times this month paints a grim and damming picture of the healthcare system failing Talia, in particular the actions of her surgeon Dr Johnny Delashaw. There’s also neurosurgeon Dr Christopher Duntsch who this week has been dubbed ‘Dr Death’. He is currently facing the possibility of life in prison following the death of one elderly women with many others who have suffered catastrophic injuries following surgery. Prosecutors in his trial have presented a list of 30 patients, which include other deaths and his best friend ending up a quadriplegic following surgery. Dr Delashaw’s skills as a surgeon were so evidently poor that one assisting Dr refused to work with him ever again after their first case together and corrective surgeon Dr Robert Henderson was so aghast that he contacted the medical school from where Dr Delashaw had graduated to see if he was an imposter. Read about it here and here.
Too often for those with pain surgery is seen a panacea. It’s not. For some however, it can be miraculous. On more than one occasion in the past 6 months I have found myself standing in theatre next to an operating table questioning why a procedure was being performed. For two patients in particular, there is no way I would have been in their shoes! One surgeon even commented to me as his patient was being closed up, “I’m not sure how he’s going to go.”
Would you go under the knife with that level of confidence in a positive outcome?
Despite people dying from it, blood-letting used to be considered helpful but now we know better. There is an ever-increasing list of surgical procedures which simply aren’t helpful, for example: stem cell injections, tennis elbow surgery, cardiac stenting, appendectomy, knee arthroscopy, epidural steroid injections, spinal cord stimulators, spinal fusions…and more. If someone cares enough to look, there are many journal articles available on the topic, but here’s an easier read from the Sydney Morning Herald written last year following confessions of Orthpaedic surgeon Dr Ian Harris.
So what’s this got to do with Physiotherapy?!
Well Physiotherapy is still on a spectrum of healthcare; we just work in treatment rooms and gym floors and use weights instead of scalpels (or if you’re really unlucky, therapeutic ultrasound, TENS and a whole host of other devices which don’t work).
The question of efficacy i.e. an intervention actually working as promoted by the therapist of believed by the client/patient, still remains.
Paul Ingraham wrote about the ‘healer syndrome’ here.
“We start believing that we can treat practically anyone, that every patient does need us, that we do offer a unique and therapeutically potent service. Selling our services turns many of us into “true believers” in our own methods and pet theories, incapable of recognizing problems with them. Self-serving behaviours can be justified by self-confidence: it’s all good when you really can help almost everyone … right? This is the most dangerous form of healer syndrome — a subtle and insidious attitude problem.”
“Pain is tough to treat, period. In your search for relief, stick to professionals who are candid about that: they are the ones who are actually more likely to find a way to take the edge off a little, and not take your money for bogus treatments. That’s mostly what makes a ‘good therapist’.”
“It is difficult to get a man to understand something when his job depends on not understanding it.” Upton Sinclair
I talked about back pain not being considered as a ‘medical issue’ by the leaders in our field in my last post here. Only a few days ago, an article written by Mary O’Keefe, Chris Maher and Kieran O’Sullivan was published in the British Journal of Sports Medicine here entitled ‘Unlocking the potential of physical activity for back pain’. “The only known effective prevention method is exercise alone or exercise and education.”
Pre-occupation with the ‘right’ types of exercises, especially complex ones only a physiotherapist can deliver, is holding us back. The ‘any form of exercise’ message is frequently diluted by the adjuncts like manual therapy and devices. A dependency upon ‘treatment’ contradicts the need for self-efficacy and for someone to feel that their spine is capable. Suggestion of ‘weakness’ and a need for in-shoe orthoses (orthotics) can induce fear and vulnerability which does more harm than good.
Back pain is due to a wide range of physical, psychological, lifestyle and social factors. We have routinely measured things like range of motion, muscle activation and strength, despite the absence of evidence linking them to low back pain, yet we don’t do the same for sleep and mood, which *have* been linked to back pain. Therapists who focus on the ‘bio’ are likely to be wrong. The sad reality is that we’re still stuck on out-dated practices; these photos were taken at the Combined Sections Meeting of the American Physical Therapy Association in Texas last week.
Many of our clients would be better serviced if our focus was on the barriers and facilitators to them being active, goal setting, intrinsic motivation, and their perceptions and experience of physical activity.
This morning I was listening to a well-known, well-respected Brisbane-based Physiotherapist with a PhD being interviewed in 2012 by David Pope on the Physioedge podcast. I’m not sure that I will listen to the rest though as much of what was being suggested or claimed in the first 15 mins is now widely recognised to be incorrect. Vladmir Janda and Shirley Sahrmann used what’s called a ‘prone hip extension test’ which was believed to demonstrate ‘correct’ firing order of muscles in the back, buttock and hamstring. Way back in 2011 Greg Lehman highlighted the lack of validity with it here; yet a year after that a prominent clinician with a PhD is still using it as a basis for diagnosis and treatment. On social media I’ve seen the same test being used by another Brisbane-based Physiotherapist promoted as ‘best-practice’, and more bullshit that I care to remember.
In the latest episode (38) of The Physio Matters Podcast here, Jack Chew discusses the role and use of manual therapy in clinical practice with Neil Langridge who earns an income teaching manual therapy courses. @TPMPodcast
They discuss the usual myths and misconceptions around alignment, things being ‘tight’ and needing to be ‘released’ by another human (hands, devices etc.) and adhesions; the Danoz direct of treatment options. These things are profitable and Physiotherapists can cash in on them, whether they’re charlatans or genuinely believe them to be true. If a client/patient has those incorrect beliefs, the Physiotherapist providing those interventions does little but reinforce the misconceptions. These are issues of behavioural change. There are clients/patients who ‘can’ change, those who can’t change, and those who are unwilling.
Suggesting to a potential client that their beliefs are unfounded and that the time and money they’ve already invested in ‘treatment’ may have been a waste isn’t going to help build a new therapeutic alliance; quite the opposite – we would likely never see them again. It’s a sensitive situation with risk of it feeling like a confrontation. Joints being locked, slipped and misaligned, and muscles being weak, tight and not switching on is a real problem for us (because it’s bullshit) and we need to choose our battles. I find it incredibly sad that there are people I cannot help simply because of the incorrect, unhelpful and harmful beliefs they have acquired from a fellow Physiotherapist.
We have a professional, moral and ethical responsibility to do the right thing by our clients/patients. Should we collude with the misinformed client or bow out? If Neil Langridge can’t see a valid clinical outcome for a manual intervention and the evidence for that patient in front of him suggests that it is not appropriate, it doesn’t matter what the patient tells him; he has to agree to disagree with the client knowing that that they will go to someone who will provide them with what they believe they need.
Does a GP prescribe antibiotics to a patient with a viral infection simply because that’s what they’ve asked for? Of course not. I’ll tell you why Physiotherapists continue to peddle such nonsense – it’s a business. A friend and local Physiotherapist here on the Gold Coast was recently described by two different people as a “used car salesman”, which was what triggered this. I would be utterly horrified if someone described me as that, BUT….most of his clients don’t see him that way and the APA (here) quite frankly doesn’t care if we run our clinics as a profit centre first and healthcare practice second.
When money is changing hands in private practice the ethical dilemmas become more of an issue because we have rent and bills to pay. Our fixed overheads are close to $10k/month. Beyond that we also need to pay staff and have enough left over to pay ourselves (which we haven’t done yet) and grow the business to help more people.
Neil Langridge was asked to leave one practice because he didn’t have enough follow-ups and told he wasn’t creating enough business. That is something which strikes a chord with me because I lost 6kg (13lb /1 stone) in my first 3 months at one practice from the stress of sales and the expectation of building a caseload upon which my salary was dependent.
Most of Neil’s patients he would see only once or twice for advice and guidance with only 1/5 now receiving ‘manual therapy’. Recall that he teaches manual therapy, which demonstrates how much clinical value and importance he places on it. It is not a dichotomy of hands-on vs hands-off – that argument is fallacious.
If you had to pay for a GP visit, how would you feel being told that you have to come back for a seemingly endless stream of visits for tests and investigations if you knew that they were unnecessary, and sold medications you didn’t need? That happens in Physiotherapy.
12-weeks is generally sufficient time for someone to recovery after most surgical procedures sufficient to at least be active. Prof Jill Cook, a leading authority on tendinopathy, describes her case load as “the desperate and dateless” – those with symptoms which haven’t been resolved elsewhere. On the Mechanical Care Forum here in episode 134/135 Jill describes how she will typically see someone with a tendinopathy only 4 or 5 times over a period of 6 months, and her programs rarely fail patients i.e. they almost always get better.
Pretty much everything gets better or feels better within 12 weeks!; it’s called ‘regression to the mean’ and ‘natural history’. If the body can heal itself after it’s been through surgery and Jill Cook can help someone with chronic tendinopathy in 4/5 sessions over six months, you have to question how frequently someone really *needs* treatment, or at least question the clinical basis for a recommendation of frequent visits over many weeks. Clients shouldn’t be paying someone for an outcome which nature and time will provide at no cost. It’s not biologically plausible for us to change what’s happening inside a client’s body from the outside.
Strengthening takes time. Some chronic diseases require a ‘supervised’ program of care. Regaining function following major trauma can be a life-long challenge. These presentations, at least in my limited experience in a private practice setting, don’t account for the majority of patient presentations in the average private practice. Regardless, the goal is always patient independence. Three treatment sessions in a week would typically be less than 1% of someone’s 168hr week; only a fool would consider that more influential in addressing Lederman’s three processes (below) than the remaining 99%. What the client *does* with their 99% when they’re on their own is what really matters. Our time is not to *do*.
Eyal Lederman wrote here that the loci of recovery and health are innate processes within the body/person, and are influenced by their environment (physical, psychological and social). Our role is to co-create with the patient environments that support these self-recovery process. We don’t ‘fix’ anything; we simply steer people in the right direction. To that end, we have three basic processes to focus on: (1) tissue repair, (2) adaptation, (3) alleviation of symptoms. Creating self-efficacy in the client/patient and having the locus of control remain with them is fundamental to helping them reach the goals which are meaningful to them. It’s not what we *do*, it’s what the patient does which is valuable.
I’ll save the specific details for another post, but I didn’t see a Physiotherapist before, during or after the repair/reconstruction of my anterior cruciate ligament in 2010 (which I’d incorrectly been told by a Sports Physio would delay inevitable arthritis) and the surgeon subsequently changed his rehab protocols based on how quickly I regained my function; go figure.
The cold reality of Physiotherapy, like surgery, is that a lot of the time we really don’t know how someone is going to go. Time and time again the treatments we’ve relied upon have later proved to be ineffective and the tests upon which we base our clinical diagnoses unreliable.
There is no evidence that any professional or treatment is actually capable of producing dramatically better results than any other. Nothing is easier to sell to people in pain than hope — they are one of the most motivated groups of potential customers imaginable.
With the odds greatly stacked in our favour, clients/patients would be wise to seek a second opinion, which I think is a sad indictment of our profession. There is a possibility that my professional, moral and ethical position may put me out of business. I’m well aware of that but I also want to be able to sleep at night!
If you’re seeing a Physiotherapist on a very regular basis because you feel you *need to* or have to, get a second opinion. Unlike being in the hands of Drs Delashaw and Duntsch, your life isn’t potentially hanging in the balance if you take a different direction.