Why I care less about anatomy

TheKettleBellPhysioBlog, Physiotherapy0 Comments

My journey to becoming a Doctor of Physiotherapy started in January 2005. Turning 30 that year, I returned to full-time study to become a Personal Trainer. It introduced me to anatomy and physiology, of which I remembered absolutely nothing from school. Not one bit. Maybe I’d learnt it and forgotten it, or not covered it at all; either way, I was starting with a clean slate.

The Personal Training qualification lead to a Massage course within the year. That meant more anatomy and the start of learning the skills of assessment and treatment in a ‘clinical’ perspective, albeit at an entry-level. The next course was a very anatomy-heavy Diploma in 2006 based on the Osteopathy text ‘Greenman’s Principles of Modern Manual Therapy’. At the end of 2007 I had returned to University and was studying full-time from 2008 to 2012 completing an Exercise Science Undergraduate Degree then Postgraduate Doctor of Physiotherapy; 13 Semesters in total.

In 2013 and 2014 I spent 18 months developing and teaching an Advanced Diploma of Myotherapy curriculum. I was very fortunate to have been handed a completely clean slate with the objective of creating a Vocational Education & Training course which would compete with Private Practice Physiotherapy. I was like a pig in poo – learning more about anatomy, movement, assessment and treatment; all the things I would have wanted to learn at Uni as a Physio student if I’d been heading into private practice. That’s also when I was introduced to and Certified in the FMS, SFMA and RKC courses.

The problem with learning more, is that the more you learn, the more you realise you don’t know. The Dunning-Kruger effect illustrates this principle very well.

The answers I once gave which were confident, definitive and given with a sense of certainty have turned into, ‘that depends’, ‘maybe’ and ‘I’m not sure’. This morning’s newsfeed was a good illustration. At University we’re taught about a ‘normal’ pattern of coordinated movement for the shoulder blade and arm; the ratio of upward movement of one relative to the other, and how movement and position of the scapula is a cause of various ‘dysfunctions’, and things like ‘scapular dyskinesis’ and impingement syndrome. We’re also told that bending forward loads interverbal discs in a way which could be a cause of low back pain, and bending and twisting to pick something up – don’t even think about it!; that disc might just explode or pop right out!! Just this morning, I’ve seen conversations around two journal articles refuting both of those topics. This happens on a *daily* basis. These are just the supposed mechanisms and cause of issues; the recommended treatments were equally daft….and they’re still happening even now.

There are plenty of things which Physiotherapists are *not* supposed to be doing, yet commonly still do. There are examples here regarding the use of ultrasound, laser, TENS and massage and here for requesting imaging of the neck, back and ankle, or treating a frozen shoulder with ongoing manual therapy. Recently published in the APA’s Journal of Physiotherapy, the paper by Traeger et al here discusses over-medicalising, over-diagnosing and over-treatment within the profession – ‘low-value Physiotherapy’. Two of my recent blog posts have covered the same topic.

Conditions like whiplash, tennis elbow, low back pain and ankle sprains do not require the medical input of a Physiotherapist. We can provide reassurance and some strategies for self-management, but they’re self-limiting conditions which will resolve all on their own, regardless of the treatment someone may have. ‘Treatment’ doesn’t change the trajectory of the symptoms. Physiotherapy should be more than simply providing a soothing intervention to make someone temporarily feel better – that’s what happens at a day spa.

Pretty much everything I once believed to be valid and reliable, I now know not to be accurate. Specificity, Sensitivity, Clinical Prediction Rules, P-values and a whole host of other academic and sciencey ‘stuff’ supposed to help guide my clinical narrative and recommendations as a clinician, has failed me. A general workflow would involve screening for potential serious ‘red flag’ pathology first, then using the highly sensitive tests to ‘rule out’ (so to speak), before reaching a clinical diagnosis having ‘ruled in’ with a highly specific test. It doesn’t really work that way of course, and we don’t rule things in or out; the tests simply add to the overall clinical picture and an educated guess. There’s also much more to it of course, such as trying to differentiate between tissues and structures, unravelling a myriad of signs and symptoms, unpicking the patient’s narrative to work out what’s important and what’s not, and communicating with the complex human being in a way which fosters a helpful alliance. Just this week on Twitter both Prof Peter O’Sullivan and Prof Chris Maher highlighted the difficulty in identifying the initial red flag part, and that’s right off the bat! After that, it typically doesn’t get any more accurate.

I’ll give you an example of my own from last year. One of our Remedial Therapists had all the typical signs and symptoms of a labral tear in her shoulder. After taking a history, ruling out what we could, two orthopaedic tests, each about 95% specific (ruling in) for a labral tear, were both positive. I’m not a statistician so I can’t say what the likelihood is of someone having two highly positive tests be positive and *not* have the condition, but that’s exactly what happened. I referred her for imaging and it came back as a plain old bursitis. The additional consultation with a GP and subsequent imaging had not been helpful and management did not change. If two tests supposedly 95% accurate at identifying a pathology were both wrong, how much trust should be put in the rest of them!? Somewhere around ‘very little’ I would suggest.

Last year Sean Overin wrote a blog here along a similar theme about Symptom Modification Procedures and the challenges of over-diagnosis, otherwise called ‘selling sickness’.

“The majority of the clinical tests we use have a diagnostic accuracy that isn’t any better than chance. Further, the proposition of labelling our patients with a biomedical diagnosis has the potential to do more harm than good, especially when we can’t validly say what the cause of their symptoms are.”

I feel it’s not so much the land of the blind, but the land of the blinded by over-complicated, poorly understood interpretations of unreliable data.

If in doubt, we recommend turning to Greg Lehman because he’s probably less wrong than most other people!
In a recent blog here wise owl Greg said this:

“Physical exams typically suck…for finding a structural source of nociception that is. We should totally try to rule out red flags and any tissue that requires healing or repair but after that they are pretty poor. Essentially, the tests just tell us what movement hurts.”

Greg goes on to suggest that we still use the same tests and symptom modification procedures, not as they’re intended, but to provide assurance and build self-confidence within a biopsychosocial framework. Through that BPS lens and with a contemporary understanding of ‘pain’ as an experience, painful symptoms now casts a huge question mark over anything painful in the absence of a clear trauma or inflammation.

We can’t even rely on our outcomes either! Kyle Ridgeway wrote about that back in 2014 here. And let’s not get started on the utility of imaging because it’s a) pretty crap and b) frequently doesn’t change how we would manage a condition anyway.

I used to focus *all* of my attention on anatomy and tissues. I spent thousands of dollars on text books learning as much as I could about as many clinical tests my brain would hold. That hasn’t turned out to be helpful. Some conditions have more than 20 tests! Just this morning, here’s Peter once again telling us what he’s done with his text books.…

I used to care about anatomy. Now I find myself not caring much about it all. If there’s clear damage or someone’s recovering from surgery or injury, then I’m going to pretty much leave it alone knowing that a process of active recovery and appropriate loading will take care of the rest. I can’t change or influence anatomy, only the way in the individual is using it. If someone has pain in the absence of tissue damage and inflammation, then tissue becomes almost irrelevant. If there’s clearly no tissue repair or adaptation required following injury or disuse, then it’s just the symptom of pain to deal with. In that case, tissues are not the focus of my attention any more, other than to reassure someone that it’s normal and all appears to be just as it should be. If I wasn’t blaming a specific tissue and trying to “fix” it with my hands somehow, I was blaming positions and movement. In a teaching role for almost a decade I used to go through my own long list of anatomical faults and dysfunctions; the flat feet, ACL-deficient knee, 13mm leg length difference, scoliosis, Scheunemann’s kyphosis, rounded shoulder and poke neck. It’s a wonder I’ve made it to 41 without falling apart. But wait, over-pronation, dynamic knee valgus, pelvic tilts, rounded shoulders… they’re not valid or reliable predictors of anything either.

Oh. Dear.

‘Evidence’; it’s nice when it supports our clinical decision making, but more often than not I’ve found that it gives us a big smack in the chops.

As an evidence-informed profession, we don’t have much to rely upon with any conviction. There’s always plenty of exciting new possibilities and emerging research, but training lumbar multifidus and patella taping were once pretty exciting…

You’re probably wondering what my approach is now. That would be a good question!

I don’t disregard anatomy. I don’t disregard the utility of ‘special tests’, or the use of manual therapy, or how someone moves. At the moment, (I expect that in another 18 months it will have changed again) I focus on movement competency and physical capacity, relative to symptoms and what someone wants or needs to be able to do. I experience the same sentiments as Adam Meakins here. I am a Personal Trainer; it’s where I started this journey and exercise/physical activity has been a fundamental part of life since I was a child. Helping people become healthy through exercise is what I’ve always wanted to do; I just do it now while wearing a hat that reads ‘Physio’ and see my clients/patients through a different lens.

Consider this scenario; two people are making you a sandwich – one is a ‘sandwich artist’ from Subway, the other is Heston Blumenthal. Heston’s creation will be based on an entirely different knowledge of the ingredients and food in general – he probably wouldn’t even use bread! You know that the two sandwiches will be very different….. but it will still be a bloody sandwich! Some people are happy with Subway (I love it) and it’s great value. Some people believe that Subway isn’t necessarily the best sandwich they could get, nor the value that they’re looking for if they want to nourish and sustain their body with something delicious.

Physiotherapy in Private Practice and Personal Training are analogous to the sandwich scenario.
Not every Physiotherapist has the finesse of a Heston Blumenthal; many seem to be sandwich artist dressed in Physio’s clothing. Here’s a text (and my reply) that I received from my wife the GP Registrar as I was writing this which sums up that lot nicely:

To wrap up, I’m stealing Adam Meakins’ final paragraph from his blog:

“I will quite happily and confidently say here now as I do to all my patients… I am just a physio. I try to help people with pain, disability or injury move and function better. I try to do this by getting people fitter, stronger, robuster, both physically and psychologically. I try to do this with advice, education, activity and exercise, not rubbing, poking, prodding, or taping. I can’t and don’t correct faulty biomechanics. I can’t and don’t change joint or tissue stiffness. I can’t and don’t miraculously cure or remove pain.”

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