In episode #55 of the Physio Edge Podcast here, Brad Neal used the phrase “do as I say, not as I do” in relation to continuing to run with knee pain.
I get it. It’s human nature. I think it’s also worth considering that when people (Physiotherapists) *do* things differently to what they may recommend, there’s probably a sensible rationale behind it, not to mention that they’re looking at the same situation through an entirely different lens.
A financial advisor for example, may recommend a term deposit and a high interest savings account, with daily strategies such as “don’t spend coins”, to a new client who has minimal savings and a history of unhelpful behaviours with money, yet invest in high-risk margin lending funds themselves.
A Physiotherapist who understands physiology and the complexity of pain for example, may choose to ‘run into pain’ yet recommend to a client/patient that they avoid that same activity all together. I have pain most days but there have been very few occasions when I have made a conscious decision to avoid joining in with a kettlebell class because of the pain. Right now, I’ve had wrist pain since doing this on the 18th of March. That was 18 days ago! It’s better than it was, but I liken the feeling in my wrist (and function) to an ankle sprain – holding a bell in a bottoms-up position, which demands more stability, is challenging and noticeably asymmetrical at the moment, which isn’t normal. On Thursday last week, I described my back as feeling like it was broken; I still trained that day and moved 10,000kg in class on Friday, and the same again at 8am on Saturday.
Would I recommend someone else do that? Well, that depends on more variables that I care to list, and my recommendation could range from “absolutely! Suck it up pissy-pants” (I wouldn’t actually say that second part, but may be thinking it) to “no. Go home, put your feet up and take the night off”.
A couple of weeks ago one of our class regulars ‘Troy’ who in the previous class has been swinging a 44kg bell, had an issue with a wrist. On the very first back-swing on his warm-up with a 16kg bell, he felt a click and pain. He then struggled to hold onto anything after that and everything he did was painful. It would have been nearly impossible for him to have caused any structural damage with what he did and I suggested that he would likely wake up in the morning and feel like nothing had happened. That’s exactly what happened. He skipped one class and that was it. Even though I was 99% certain that he hadn’t caused any damage, I felt certain that pushing into pain probably wasn’t going to be helpful. We could have both freaked out about potential damage to his triangular fibrocartilage complex, but we didn’t – the value of perspective. Troy doesn’t know what a TFCC is, and hopefully never will; he doesn’t need to know – I do.
All that said, there’s also the other side of the “do as I say, not as I do” coin.
Too often we err on the side of caution and avoid recommending the very things that we *would* do and would be helpful. Yesterday I shared a Facebook live video of me completing the Y-Balance Test and M.A.T. test after two recent podcasts with Dr Eammon Delahunt (PhD) discussing ankle instability – The Physio Matters Podcast here and BMJ Talk Medicine podcast here. Just yesterday, Rod Whitely shared his thoughts from an Aspetar lecture by Dr Phil Glasgow (PhD) entitled ‘Optimising load in rehabilitation to maximise adaptation and minimise recurrence’. I agree with Physiotherapist Mick Hughes: “Let symptoms guide recovery and rehabilitation”. Here is the effect of immobilising a ligament rather than encouraging normal movement and returning to loading as tolerated. I would suggest a similar principle could be applied to most things in rehabilitation. I shared the current guidelines for managing ankle sprains here, and I’m forever banging on about the importance of older adults being active and not treated as frail.
Far too often in Physiotherapy, clients/patients are doing things which just aren’t helpful – ‘inappropriately loading’ covers the spectrum of too little (or none) to too much. I’ll be the first to admit that getting it right for an individual is more an art than science, and was involved in a brief discussion with Ben Cormack on his Facebook page about just that topic recently. Here’s Ben’s blog post about loading and dose-response.
I’m a passionate believer in ‘The Mum Test’; I ask myself, “would I pay for my mum to be doing this?”
If the answer is a resounding “No”, then we probably shouldn’t be recommending it to anyone else!
In my next post, I’ll share my own experience following the (unnecessary) surgical repair of the anterior cruciate ligament in my knee. My surgeon Dr Chris Vertullo told me to see a Physio and suggested Brad Beer at POGO (who I’d known for many years and subsequently went to work for); I never saw a Physio.