I don’t care how open-minded, motivated, or ambitious you think you are, you suck at changing your mind, your opinions, and most definitely you suck at changing your actions and behaviours! But don’t worry, it’s not just you, everyone sucks at change… and I mean everyone!
So it’s that time of year again when we all start to think about making some changes to our lives. Be that eating a little less, exercising a little more, or just doing something different. However, most of us will not stick to our New Year’s resolutions with some research showing 25% fail within the first week and as little as 8% are ever achieved.
So it’s safe to say that behaviour change is difficult for all of us, and it frustrates the hell out of me when I see physios and other healthcare professionals talking about behaviour change as if it’s something that occurs easily. However, I also get just s frustrated at those who over-complicate the shit out of behaviour change using loads of neuro-psycho-social-science babble that they don’t even understand themselves.
Personally, I think behaviour change is actually pretty simple in theory but incredibly difficult in practice, and so I want to discuss a few of the common issues and barriers that occur when we attempt to change our behaviour such as trying to exercise a bit more or eat a bit less and also look at some simple but not easy ways to try and overcome them.
Lower Your Expectations
The first issue with change is that we all tend to expect it to occur quickly and so we all tend to get very demoralised and demotivated when it doesn’t. Simply put change doesn’t happen overnight, and if it does it usually happens due to things out of our control or despite of what we may or may not have done.
When we do attempt to change things such as eating less or exercising more we often totally underestimate how long it takes for these changes to be noticed. For example, 1 month of eating in a sensible calorie deficit will, if your lucky, lose you about 5lb or 2.5kg in weight, and the effect of this on your body composition will be minimal to negligible.
So to avoid getting demotivated and demoralised set your expectations much lower than you anticipated, and then set them even lower still. If you thought 3-6 months of dieting was going make you look like a toned goddess or a rippling adonis, reset those expections to hopfully looking less like a wet sack of sand or unset custard tart when you take your clothes off rather than Brad Pitt or Kate Moss back in the 90’s
Break The Habit
Without doubt one of the biggest challenges of behaviour change is overcoming our innate ingrained habits. Habits are automatic behaviours that we learn over time, and they can become extremely difficult to break. Our habits can become so automatic that we don’t even know when they are occurring and they can be triggered by things we don’t even notice such as a smell, a location, or the presence of a certain person or object. To overcome this it is important to identify these triggers that lead to our bad habits and either remove the trigger completely or replace the habit with another healthier one.
For example, if you find yourself automatically reaching for the chocolate cookies in the evening once you’ve sat down on the sofa with your cup of tea and your favorite soap opera. Either remove all the chocolate biscuits from your house making it harder to get a damn cookie, or replace those delicious cookies with something else healthier if not a little less delicious. Personally, I find replacing habits rather than trying to remove them a much better strategy as my old ‘primeval lizard brain’ doesn’t feel as hard done by and is less likely to hit the ‘fuck it button’ and give up on it completely.
Another challenge of behaviour change is self-control. Self-control is our ability to resist temptation or overcome our impulses, and it can be a significant problem when trying to change our behaviour. For example, if you are trying to quit smoking or drinking, you will have to resist the urge to smoke when you are stressed or in social situations where others are smoking and drinking.
Self-control can be challenging because it requires both mental and physical effort, which can be difficult to maintain over time. To overcome this it is important to develop strategies for self-control, such as setting goals, creating a plan, and enlisting the support of friends and family but most importantly not relying on ‘motivation’ to keep you going.
I have discussed the issues with motivationbefore, explaining how it can be a powerful but short-lasting stimulus to help us pursue our goals and to make behaviour changes. Motivation is incredibly difficult, if not impossible to maintain for the long term, especially if we encounter setbacks along the way. To overcome the issue with motivation I think it’s vital to not rely on it much at all and rather develop some experience and exposure to doing things when you feel the LEAST motivated to do them.
Developing some exposure and self-discipline to ‘getting shit done’ when you’re not motivated is essential to changing your behaviour. Developing some resilience to doing things when you feel like doing them the least will give you the ability to take some control and ownership over your behaviours. However, this isn’t easy and there will be lots of times when you fail to do this, and that’s ok and just as essential to deal with.
How you deal with inevitable failures is another key feature of behaviour change. Those who give up and hit the ‘fuck it button’ won’t change. Those who accept and learn from their failures, don’t beat themselves up, or look to blame others will have more chances of succeeding.
A nice rule for dealing with the inevitable failures of behaviour change such as missed training sessions or eating those secretly stashed chocolate cookies is don’t fail twice in a row. Failing once is to be expected and often due to things outside of your control, failing twice in quick succession is often a choice.
Ditch The Haters
Another challenge of behaviour change is overcoming the many barriers you will face. Barriers are external factors that can make it difficult for us to change our behaviour, things such as conflicting priorities, a lack of resources, or often a lack of support. Although you should never rely on others’ support to change your behavior, surrounding yourself with people who do support you does make it easier.
However, what’s more important here is you remove yourself as far as possible from those who look to put doubts in your mind, discourage you, or ridicule your attempts for change. Although using the hater’s negative emotions can fuel your fire, it will eventually make you bitter and bring you down to their sad and pathetic level of existence… so “fuck the haters” and keep on keeping on!
So in conclusion, changing our behavior can be a hugely difficult and challenging process, and it is not uncommon for us to struggle and fail to make lasting changes to our behavior. However, it’s not impossible, and you can succeed. Understanding and recognising some of the challenges that arise such as overcoming unconscious habits, developing self-control, not relying on motivation, and dealing with failure will help you.
So good luck with your New Year’s resolutions and although many do fail please take heart that those who do make a commitment to change at this time of year are still 10x more likely to succeed than at any other time of the year.
Happy New Year and all the best for a healthy and prosperous 2023
“Why isn’t this feeling like it did when you first did it? This doesn’t make any sense… what the hell am I supposed to do now?”
This was what a patient said to me about 5-6 years ago, who was suffering from severe sub-acromial shoulder pain as I was trying to find a way to reduce her pain on movement, just like I had achieved 10 minutes ago when I used the Scapula Assistance Test on her. Unfortunately, I didn’t have a good answer to give her, and this was also the last time I used this test and many others like it… let me explain why.
The Scapula Assistance Test is a commonly used shoulder symptom modification test first described by Ben Kibler in 1998 in which a therapist attempts to ‘assist’ the scapula into upward rotation as a person lifts their arm to see if this reduces their painful shoulder experience. There are many other tests that can be done around a painful shoulder to try and reduce a painful movement, most of them conceived by Jeremy Lewis in his Shoulder Symptom Modification Procedure (SSMP).
But symptom modification tests have also described around many other body areas such as elbows, hands, knees, hips, necks and backs and they sometimes go by the names NAGS, SNAGS, or MWM’s as conceived by Brian Mulligan.
However, I now just refer to all these kinds of tests as ‘clinical magic tricks’.
Now I was taught many of these ‘clinical magic tricks’ by some very well-known and influential physios on their courses and they assured me that if you can get a patient’s painful movement to quickly change using their ‘techniques’ it will help patients understand their pain is changeable and help them move more and with more confidence and improve their prognosis and outcomes (ref).
However, after a few years of using them, I began to realise this was not always true, in fact, I found it was often not true at all.
I began to notice that these ‘clinical magic tricks’ were first of all not reliable or reproducible on the same patient which lead me to conduct my first clinical research trial to check my observations under more controlled conditions (ref). Not only did I find very little reliability or reproducibility, but I also noticed that these ‘clinical magic tricks’ can have some negative and detrimental effects for some patients that no one ever mentions or talks about.
I found that sometimes if I suddenly and dramatically reduced a patient’s painful movement with one of these tricks… after the shock and excitement had calmed down it left many patients, and myself, feeling a little confused and uncertain about what had just happened, and what should be done next.
I found these tricks confused me and my patients the most when we couldn’t repeat the results the next time we tried them, or if we couldn’t reproduce the results without me pushing, pressing, or pulling on them. This left both of us feeling unsure and uncertain about what was going on and what we should do.
I mean just think about it for a second… if you had a pain that suddenly changed or disappeared completely when someone pressed or pushed something, only for it to reappear just as suddenly unless someone was pushing or pressing you, do you think you would be reassured or confused?
I was also taught that the way to explain these tricks to patients if they worked was based around a biomechanical explanation such as the scapula or another joint was out of position, misaligned, or not moving correctly, or that a muscle was weak or unbalanced. But this is just outdated reductionist bullshit.
First, there is no evidence that when we push or pull on someone’s scapula or any other joint and they feel less pain, it tells us if their muscles are or are not functioning (ref). Next, there is no evidence that pushing or pulling on a scapula actually significantly changes the scapula position or movement (ref). And finally, we see no difference in the effects of these symptom modification tests when we compare them against sham or placebo tests, telling us that the biomechanical explanations can not explain the results alone (ref).
Simply put there are many, many probable reasons why someone’s pain changes as we push, press, and pull on their scapula or any other body part. It could be due to increased proprioceptive input from the therapists’ hands, or increased feelings of safety and security for the patient as they move, or expectation violation as they move… the list of alternative explanations as to how these clinical magic tricks reduce pain is almost endless.
And if we do try to explain the complex and multifactorial nature of pain and how there is a lot of uncertainty in the why or how their pain changed as we do these clinical magic tricks this, in my opinion often doesn’t help reassure many people, instead, it just adds another level of confusion and more uncertainty unnecessarily into an already confusing and uncertain situation.
And finally, I was also told that these symptom modification tests help us direct our treatment interventions better. But again this is a complete load of bullshit. Just because you reduce someone’s pain by assisting their scapula it doesn’t mean you need to or can give treatments or exercises that change the scapula’s movement or position well at all (ref).
So using these symptom modification tests or clinical magic tricks to reduce pain just doesn’t sit well for me today in many clinical situations where I have fully listened to the patient’s history, thoroughly assessed their movement and pain levels, and reassured myself, and hopefully, the patient as well that there is nothing serious or harmful to be concerned about.
It also doesn’t make sense for me to spend time explaining and reassuring patients that the natural history of their issues is complex but favorable, and then discuss with them how they can continue to do things they need or love to do without any fear of doing any further harm or detriment to themselves or their prognosis, only to suddenly say…. “but hey… lets still try to reduce this perfectly safe yet unpleasant pain anyway”. This seems like such a huge contradiction.
So there you go… that’s a very quick look at the Scapula Assistance Test and the other symptom modification procedures or tests that are often recommended and promoted to help reduce painful movements. And although I do understand why they can be appealing and attractive to learn and use in clinical practice, and they can help some patients, sometimes, for a short while… please do not be fooled into thinking they are reliable, diagnostic, or essential to do with most people.
In fact, I would argue that these clinical magic tricks are often more for the therapist’s benefit than the patients, giving therapists a sense of utility, usefulness, and skill in being able to fix and correct things. For most patients, they are not really that useful or that beneficial, and as I have mentioned they can have some negative and detrimental effects that no one ever discusses or talks about, which I hope this blog changes.
Vested Interests and Weak Egos
Now I know this blog will upset some people, usually those with vested interests and strong biases into teaching these ‘clinical magic tricks’ as well as a few other therapists with fragile egos and low emotional intelligence who often hide behind anonymous social media accounts and cannot tolerate anyone questioning, challenging, or criticizing their beliefs or ways of practicing (see below for a perfect recent example)
However, please do not let either the gurus or trolls put you off from questioning, challenging, or criticizing anything with their lame personal attacks claiming you need to ‘do more research’ or ‘criticize less’ as this reflects more about their issues and insecurities rather than yours.
As always thanks for reading, and please stay skeptical, keep questioning and remember there are no sacred cows in physio… even those who teach ‘clinical magic tricks’.
So it’s been a while since I’ve blogged and even longer since I’ve had a guest blogger on The Sports Physio. However, I am really pleased to introduce you all to Marcus Blumensaat who has done an awesome post on that tricky and elusive question of… how much exercise is enough?
Why do we even care to know?
Many people do not like to exercise. At all. They do not want to perform exercises even if they have been told by a health care professional that it will help them to recover, heal or rehabilitate an ‘injury’. In my opinion, getting people to perform their prescribed exercises is one of, if not the most, challenging things we face as musculoskeletal (MSK) health care practitioners.
Many people don’t even meet public health exercise recommendations that have been shown to decrease all-cause mortality by 40%.1 40%!!! I suppose they are on the ‘we are here for a good time, not a long time’ train. Fair enough, I have been on and off that train many times. I usually buy a ticket when a freshly baked chocolate chip cookie is in front of me.
Back to the clinical setting… if a person is seeking our help and we have employed our critical thinking in a biopsychosocial (BPS) framework and have determined that the performance of exercise would be beneficial to the case at hand, the answer to this question, ‘what is the minimal effective dose?’, is very important indeed.
If we knew the minimum effective dosage of exercise, one would assume that we would increase the odds of the people we are working with actually performing the prescribed exercise(s). With the end result being better clinical outcomes, i.e., happier, healthier people!
Thus, it would be to everyone’s advantage if we could figure out what the minimal effective dose of exercise is for different pathologies and pain. Simple.
Like most questions in the MSK world regarding pathologies, pain, and rehabilitation, this one of ‘what is the minimal effective dose of exercise?’ is shrouded in uncertainty.
If one exercises (pun intended) their critical thinking skills when contemplating this question, it should become obvious that there are a few details that need to be clarified before trying to come up with an answer.
Most importantly, what is the desired ‘outcome’ or ‘effect’ that you are trying to stimulate in the person by having them perform the prescribed exercise? In other words, what are you hoping to accomplish by having the person perform the exercise?
Are you hoping to change their ‘capacity’ in some way to better handle the loads* that they face in life? Perhaps the goal is an increase in strength or range of motion.
* Load is the burden (single or multiple mechanical, psychological, or social stressors) that is applied to a human biological system (including subcellular elements, a single cell, tissues, one or more multiple organ systems, or the individual).2
Are you trying to decrease someone’s fear of movement (kinesiophobia) or increase someone’s confidence in using their body?
Are you trying to help them improve their mental health? Perhaps attempting to help decrease their stress levels or symptoms of anxiety or depression?
Are you trying to alter their pain experience? Help to decrease their self-reported level of pain?
Or are you trying to stimulate mechanotransduction in tissues thought to be in need of morphological or structural change?
Reflecting on and having a clear understanding of what you are trying to accomplish by having someone perform a certain exercise, will drastically affect not only your choice of exercise but also the variables (frequency, intensity, volume, rest) of your exercise prescription.
The ‘minimal effective dose’ will look very different for each of the above-mentioned ‘goals’ or desired ’outcomes’.
When it comes to strength and other physiological ‘capacities’, I would like to say that there is some certainty around the prescription variables to stimulate adaptations; but, even in this realm, there is new research coming to light that questions our old beliefs.
Strength & Conditioning
There are many components of physical fitness we could talk about, strength, power, aerobic capacity, aerobic power, anaerobic power, range of motion, etc. I would like to keep this blog focused more on pathology and pain so we will only briefly discuss the strength and conditioning (S&C) realm.
Many of these components of physical ‘capacity’ have generally accepted ‘minimal effective doses’ to stimulate desired adaptations at a population level. However, even some of these long-held beliefs are being challenged by studies and systematic reviews that have recently been published.
For instance, there was a great review3 that looked at the traditional ‘repetition continuum’ (Figure 1) which postulates that heavy load training optimizes/increases maximal strength, moderate load training optimizes/increases muscle hypertrophy, and low-load training optimizes/increases local muscular endurance.
Based on emerging evidence, the authors proposed a new paradigm whereby muscular adaptations can be obtained, and in some cases optimized, across a wide spectrum of loading zones (Figure 2). So, in some instances, it is not necessary to expose someone to as heavy loads as once thought to stimulate change.
This is especially true for stimulating muscle hypertrophy where the literature indicates that similar whole muscle growth (i.e., muscle thickness, cross-sectional area) can be achieved across a wide spectrum of loading ranges ≥ ~30% 1 Repetition Maximum (RM).
More recently, a randomized controlled trial was performed that compared moderate load (70% 1RM) with low load (30% 1RM) and measured lean body mass (LBM), 1RM strength and Fat Mass Loss after twelve weeks. Their study showed that twelve weeks of high-intensity functional training with either low or moderate loads resulted in an equal increase in LBM and 1-RM strength (Figure 3).4
So it seems the minimal effective dose may be lower than what we thought in the past.
These new findings have major implications for clinical practice as it is much easier to implement lower load exercises with people than heavier loads. Oftentimes people don’t have access to the equipment necessary to perform the heavier loads. Some people are scared that they are going to hurt themselves with the heavier loads. Some clinicians are scared that they are going to hurt people with such heavy loads.
From a practicality standpoint, anytime I see a randomized controlled trial (RCT) or systematic review (SR) that shows we can be effective with lower ‘loads’ than previously thought, I am stoked, do some fist pumps, and eat another chocolate chip cookie.
Ingesting cookies is one way to get a mental lift, exercise is another.
Exercise has long been shown to have positive effects on mental health.5 In an MSK clinical setting, decreasing someone’s anxiety or depression will not usually be one of your primary goals; however, decreasing someone’s fear around movement and their associated fear-avoidant behaviours is a common goal you may prioritize.
Graded exposure to feared movements is a fantastic approach to decrease fear around them. The exercise prescription for graded exposure to reduce fear will look vastly different than for S&C purposes as you are trying to create psychological changes versus physical changes.
One thing that you would want to be mindful of is not creating a pain flare as this could further exacerbate the fear-avoidant behaviour and unhelpful beliefs around movement that the person already possesses. In these cases, it would be incredibly important to start at a very minimal dose that is easily tolerated. Let the person experience that they can perform a version of the feared movement with no repercussions. This helps reduce their negative expectations and can start to create new, positive expectations around the feared movements.
“Reassurance is a bloody good pain killer”
I believe that experienced physical reassurance is more powerful than verbal reassurance. In other words, a person is far more likely to have less fear and more confidence around feared movements if they experience they are safe when performing them versus being told that they are safe to perform them.
Simply begin at a tolerable dose for the individual and gradually progress. This initial, tolerable dose will usually be much less than the dose required to stimulate the physical changes that you would be looking for in an S&C setting or even in a clinical setting when trying to stimulate mechanotransduction of some sort.
When it comes to pathologies we see in the clinic, there are some accepted minimal effective doses for exercise prescription, but they too continue to evolve and change. Let us look at a couple of the most common conditions that we see in a clinical setting – tendinopathy and OA.
It is widely accepted that progressive tendon loading programs are the most effective conservative approach in the treatment of tendinopathy.6 Traditionally it was thought that to effect change in tendons you had to use heavy loads (70% 1RM). A recent study showed that in fact, you may not have to.
In a recent RCT it was found that there was no superior effect of exercising with a high load (90% 1RM) magnitude compared with a moderate load (55% 1RM) magnitude for the clinical outcome, tendon structure, or tendon function in the treatment of patellar tendinopathy.7
Regarding OA, a recent study looked at high-intensity strength training versus low-intensity strength training versus an attention control group (received 60 min educational workshops biweekly for 6 months and monthly thereafter). There was not a significant difference in self-reported pain between the three groups of subjects. In other words, low-intensity training was just as effective at decreasing self-reported pain in individuals with knee OA as high-intensity training.8
What is fascinating from this study is the group who did not perform strength training and only participated in regular educational workshops did equally as well as the two exercise groups!
Perhaps we are seeing the power of high-quality patient ‘education’ at play here?! In my opinion, we can often have a more powerful effect on clinical outcomes with the ‘education’ that we deliver versus any exercise prescription or passive therapy that we perform.
Often, ruling out red flags, reassuring the person (when indicated), encouraging the resumption of meaningful/valued activities at a tolerable level, and letting natural history do its thing is all we need to do to see successful clinical outcomes!
Just so that my movement optimism bias isn’t getting worried, I think it is worth clarifying that there is a copious amount of research showing that exercise of all types, including strength training, benefits those with OA and is a primary recommendation in clinical practice guidelines.9-13
It should be noted that there is not a significant difference in effect between the different types of land-based exercise interventions.14 The most beneficial exercise is probably just the one that the person is actually going to perform!
First off, let’s get on the same page regarding pain. I will assume that those of you reading this blog understand that pain is multifactorial (Figure 4) and rarely mediated by only one ‘thing’.
Even when we are talking about someone who has had a trauma, such as falling off a ladder, their resultant self-reported pain levels are affected by numerous factors. Things such as previous experiences, beliefs, emotional factors (stress, fear, anxiety, etc.), and quality of sleep, to name but a few.
Though we know that exercise helps reduce self-reported pain16, we do not know how it does this.
Pain is so multifactorial, and the concurrent effects of exercise are so numerous, that the potential combinations of ways that exercise could decrease pain are nearly infinite. I believe that it is a little presumptuous for us to think that we can explain the physiological and psychological mechanisms simultaneously occurring during exercise and exactly how those mechanisms are decreasing pain in an individual.
On any given day, exercise probably decreases pain in different ways in each individual case due to ever-changing contextual factors. Exercise also probably decreases pain in different ways from individual to individual due to the heterogeneity of the biopsychosocial factors in each person’s life.
In relation to this, there are many unknowns when it comes to the minimal effective dose of exercise to reduce pain.
In my opinion, there is not, and there may never be, an exact ‘recipe’ that exists for the minimal effective dose of exercise.
Although there is a significant amount of evidence in the literature suggesting exercise as an efficacious modality for the treatment of chronic pain, there is virtually no knowledge of the appropriate dose of exercise for a given disease or patient type.16
At the centre of this uncertainty, is the uniqueness of each human being.
N = 1 → Person-Centred Care
The minimal effective dose of exercise depends not only on what you are trying to accomplish but also on who the person in front of you is. Randomized Controlled Trials (RCTs) and Systematic Reviews (SRs) show us population-level data, but we are attempting to use that data to help guide our care of individuals that we see in a clinical setting.
In the clinical setting n=1.
A dose that is effective for one person may not be effective for another person.
What may be enough of a dose to change someone’s fear around a movement, may not be enough to change another person’s fear around the same movement.
A dose that is effective for reducing someone’s knee pain related to OA may not be effective for someone else who is suffering from knee pain related to OA.
For that matter, a dose that is effective for a person on Tuesday may not be effective for the same person on Friday!!!
Simplifying with a Person-Centred, Macro Persepective Approach in a Biopsychosocial Framework
Yes, the irony of the above heading was intended.
I believe we often overcomplicate things by trying to figure out specific recipes of sets, reps, intensity, duration, and frequency when prescribing exercise to simulate a change in physical ‘capacities’ or stimulate mechanotransduction. If we simply revisit the most basic principles of human physiology, it may allow us to simplify our approach.
The Overload Principle states that cells, tissues, organs, and systems adapt to loads that exceed what they are normally required to do. While the Specificity Principle states that overload results in adaptations specific to those cells, tissues, organs, or systems that have been overloaded.
You simply need to prescribe exercise at a level that is more than the person is currently adapted to and you will be stimulating adaptations.
This is an n=1 approach that accounts for individual heterogeneity in the population. The person who is performing the exercise simply needs to feel like it is difficult, challenging and is harder than other things that they are currently doing in their life.
This last point is very important. Though I have cited a couple of studies that have shown you can often be effective with a smaller dose than was once thought necessary, I feel that we often are under-loading people with our exercise prescription dosages.
By considering all the demands in a person’s life, you may realize that the exercise dosage you have prescribed is not harder than many other tasks that they must perform in life with the same tissues. Thus, you probably are not stimulating the adaptations that you are hoping to.
If you and the people you are working with are not seeing the changes that were hoped for, increasing the dosage would be one of the first things that you should consider doing.
I believe a person-centred approach is even more important when the primary goal of the exercise prescription is to help improve someone’s mental health, or to reduce their pain or kinesiophobia.
There is so much more uncertainty with these outcomes due to the increased involvement of psychological factors relative to cases where a physical change is the main outcome being measured.
Knowing the person in front of you will help you to better tailor your exercise prescription. Are they timid, fearful, anxious, depressed? Are they confident, happy, or resilient?
Do they have past experiences with pain, with pain in this region of their body? Has someone close to them experienced similar pain? Do they persist through pain? Or do they avoid feeling pain?
Do they have support? Do they want to change? Is pain a major part of their identity?
The reason that finding a minimal effective dose of exercise is so difficult is that we are all so different. The answers to the above questions, as well as to numerous other relevant questions, will be vastly different for each person we see in our clinics.
Let’s just have a little fun and say that we figure out the minimal effective dose for the person in front of us. Now the real challenge is having them perform the frickin exercises!!!
To me, this is the biggest challenge in prescribing exercise and/or movement in the health care setting. Earlier this year, I wrote a blog in which I touched on some strategies to help increase adherence to prescribed exercises. You can prescribe the perfect exercise at the perfect dose, but it doesn’t matter if the person does not perform it.
I digress…this blog may not have provided any concrete answers to ‘what is the minimal effective dose of exercise?’, but I hope that it got your cogs rotating (your upstairs cogs that is) on some of the pertinent topics surrounding exercise dosage in MSK health care.
It also stroked my movement optimism bias, touching on some of the different ways that exercise can stimulate positive changes in people’s lives.
Delving deeper into this topic reinforced to me the importance of n=1 in the clinical setting. In my opinion, it is so vitally important to work in a person-centred manner.
Who is the person in front of you? Where are they? And where do they want to be? The answers to these questions can help the two of you collaborate and determine a starting point of what to do, and how much, how often, and how intensely to do it. From there, it is a process of trial and error, re-evaluating and modifying according to the person’s reaction to the initial prescription.
Though we may not know with certainty what the minimal effective dose is, I hope that we continue to encourage people to move more and challenge themselves physically because there are so many primary and secondary benefits associated with movement. As I like to say, “Every move counts.” And as a wise man once said…
Zhao, M., Veeranki, S., Magnussen, C., Xi, B. (2020). Recommended physical activity and all cause and cause specific mortality in US adults: Prospective cohort study. BMJ, 370:m2031. https://doi.org/10.1136/bmj.m2031
Soligard, T., Schwellnus, M., Alonso, J., et al. (2016). How much is too much? (Part 1) International Olympic Committee consensus statement on load in sport and risk of injury. British Journal of Sports Medicine, 50(17), 1030-1041. Doi: http://dx.doi.org/10.1136/bjsports-2016-096581
Schoenfeld, B. J., Grgic, J., Van Every, D. W., & Plotkin, D. L. (2021). Loading Recommendations for Muscle Strength, Hypertrophy, and Local Endurance: A Re-Examination of the Repetition Continuum. Sports (Basel, Switzerland), 9(2), 32. https://doi.org/10.3390/sports9020032
Kapsis, D. P., Tsoukos, A., Psarraki, M. P., Douda, H. T., Smilios, I., & Bogdanis, G. C. (2022). Changes in Body Composition and Strength after 12 Weeks of High-Intensity Functional Training with Two Different Loads in Physically Active Men and Women: A Randomized Controlled Study. Sports (Basel, Switzerland), 10(1), 7. https://doi.org/10.3390/sports10010007
Sharma, A., Madaan, V., & Petty, F. D. (2006). Exercise for mental health. Primary care companion to the Journal of clinical psychiatry, 8(2), 106. https://doi.org/10.4088/pcc.v08n0208a
Millar, N. L., Silbernagel, K. G., Thorborg, K., Kirwan, P. D., Galatz, L. M., Abrams, G. D., Murrell, G., McInnes, I. B., & Rodeo, S. A. (2021). Tendinopathy. Nature reviews. Disease primers, 7(1), 1. https://doi.org/10.1038/s41572-020-00234-1
Agergaard, A., Svensson, R., Malmgaard-Clausen, N., Couppé, C., Hjortshoej, M., Doessing, S., Kjaer, M., Magnusson, S. (2021) Clinical outcomes, structure, and function improve with both heavy and moderate loads in the treatment of patellar tendinopathy: A randomized clinical trial. Am J Sports Med;49(4):982-993. doi: 10.1177/0363546520988741.
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There is a common and popular belief that you should keep your back straight, stiff, and neutral as Switzerland when you lift things to reduce your risk of back pain and injury, and this is one of the most divisive debates I regularly have with so many people. However, it’s just not true!
Now before you all rush off to the comments section to post some PubMed links of your favourite moustached spine-saving guru’s research… Let me make it as clear as I possibly can, that I’m not saying we don’t have to or should NEVER lift some things, sometimes, with stiff, straight spines.
All I am saying is don’t be fooled into thinking that lifting something with a stiffer, straighter, more neutral spine reduces your risk of back pain or spinal injury. Because it’s just not that simple!
Where’s Your Evidence?
But where’s your proof and evidence for this Adam… I can all hear you all screaming through your laptops and mobile phones. Well, my evidence that lifting with stiffer, straighter spines doesn’t help reduce low back includes hundreds of thousands, if not millions of people over decades who have all been taught to lift things with stiff, straight backs, day in, day out at work.
The evidence I am talking about are the papers looking into the effectiveness, or rather I should say, the ineffectiveness of Workplace Manual Handling Training at reducing the rates of occupational back pain and injury.
So workplace Health and Safety Laws and compulsory Manual Handling Training was introduced in the UK over 50 years ago back in the early 1970s in an effort to protect employees from unfair and unsafe working environments and practices, as well as protect employers from high levels of employee absence and litigation due to workplace injuries. (ref)
These laws stated that all employers had to regularly educate and train all their employees, in both manual and non-manual based jobs on the importance and need for correct posture, workplace ergonomics and safe lifting techniques. This meant all employees are taught to lift anything weighing over 10kg close to the body and with a straight spine to avoid the risk of a back injury.
However, the unfortunate and unconformable facts are that these laws and this training haven’t reduced the incidence or prevalence of back pain or injuries in the workplace (ref). Now there are many questions as to why these workplace manual handling guidelines haven’t reduced rates of back pain or injury in the workplace, such as they weren’t adhered to by employees, or they were conducted properly by employers, or because back pain and injuries are multifactorial and not easily solved by simply asking people to pick things up a certain way.
Either way, the evidence tells us that Manual Handling Training that attempts to teach and train people to lift things with straight, stiff, neutral spines clearly does NOT reduce the risk, or rates of workplace back pain or injury significantly (ref, ref, ref). Yet it still continues on as if it does… this is utter madness… not to mention a day of my life wasted every year working in the NHS!
Burying Dead Bodies
So if keeping our backs stiff and straight when lifting things at work doesn’t significantly reduce our chances of getting back pain, what about when training at the gym? Or at home lifting the laundry basket? Or out in the woods trying to dispose of that pesky dead body you’ve had hanging around for a while? Well, the answer is… we just don’t know as there’s no substantial robust evidence either way.
However, I doubt that lifting technique is a significant factor in most back pains or injuries, in most people, most of the time. Even though a lot of back pain occurs when lifting, it doesn’t mean the lifting was the cause of the back pain. All back pain is complex and multifactorial, meaning it’s never caused by one, sole, isolated, independent factor such as how you lift something (ref).
Yes ok, lifting technique may have a part to play in some back pain, in some people, but if it does, it’s a small part, and usually the last contributing factor in a long list. For most people who hurt their back lifting there will be many other factors that contributed for far longer and far more, things such as their age, ability, strength, endurance, rest, recovery, capacity, capability, confidence, experience, exposure etc. All of these factors and many others determine if someone may or may not get an episode of back pain as they lift something.
When it comes to the risks of back pain and injury when lifting it may not matter that much how you lift things, but rather if you are ready and prepared to lift things, both physically and psychologically.
Lift With Your Back
It could also be argued that the constant advice to only lift with a straight back could be one of the reasons FOR the increasing amounts of back pain in our populations (ref). Constantly telling people to avoid bending, flexing, and twisting their backs under loads, can leave them weakened, deconditioned and under-prepared to tolerate these stress and strains when they inevitably occur in life.
It’s simply impossible, not to mention highly impractical, to avoid spinal flexion under loads and other forces such as shear and compression. It is, therefore, in my opinion, essential to prepare our spines to tolerate these loads and forces with gradual graded exposure to ensure they are robust and resilient.
Our constant advice to constantly avoid spinal movements outside of neutral is, in my opinion, a significant reason for the steady increase in chronic persistent back pain. I think all spines, in all people, need to be exposed to all movements, and all varieties of loads and forces, including spinal flexion when lifting things,
I think being exposed to and prepared for spinal flexion under load is both sensible and very much needed for many. However, as always there are exceptions to every rule, and I will admit that there are some people who find spinal flexion under loads to be painful and provocative and so avoiding this for a period of time to let it settle is sensible.
However, this avoidance should never be permanent, because for me the craziest thing any physio, coach, or trainer can do is ask someone to only do something, like lifting, one way all the time, forever. This would be like asking someone to only eat one type of food forever, drink one type of beer forever, or listen to one physio on the internet forever. This would be both disturbing and depressing and we would never dream of telling people this, so why is it any different with movement and exercises such as lifting.
So I hope you found this short read around lifting interesting, and I hope I have managed to convince or sway you a bit that simply educating, coaching, or telling someone to lift things with a straight back doesn’t automatically reduce their risk of back pain or injury.
So until next time… stay frosty… and remember you can’t go wrong trying to get strong… Now go lift something, those dead bodies ain’t gonna bury themselves!
Do people with the same musculoskeletal diagnosis need the same treatment to get better? Do those with tendinopathy always need to load it? Do those with chronic low back pain always need pain education or spinal manipulation? Well, the simple answer is no, but also yes! Confused? So am I… so let me try to expand a bit more.
The topic of using standardised evidence-based treatments and protocols for specific pathologies and diagnoses in musculoskeletal physiotherapy is something I have always been interested in. But I have been thinking about it more recently due to the growing research that highlights there is very little difference in outcomes with different treatments for individuals with similar problems or pathologies (ref, ref, ref).
IT’S A SHAM!
This is also true when our physio treatments are occasionally compared to shams or placebos, with research again often finding very little difference in outcomes (ref, ref, ref). Now, I don’t want to get too nihilistic or despondent here but the awkward and uncomfortable truth for musculoskeletal physiotherapy is that a lot of its treatments just don’t seem to do much over and above placebo, time, and natural history, be that massage or manipulations, needles, tapes, suction cups, scrappy tools or electro machines that go bing.
This is also true for our exercise-based treatments, be that simple strengthening, stretching, or mobilising exercises, even the overly complicated motor control corrective exercise claptrap. They all seem to do very similar things for most people with similar problems and pathologies, and that is they don’t do much more than distract people in pain whilst natural history kicks in (ref).
So this has left me wondering if it really matters that much in the big ol’ grand scheme of things what the hell us physios get our patients doing if it all has similar effects and is all not that much better than doing nothing? Does it really matter if someone with back pain gets spinal manipulations or deadlifts? Does it really matter if someone with patellofemoral knee pain gets k-tape or glute exercises?
Well, again yes it does and no it doesn’t! Still confused… well hold on a bit longer and I will try and clarify soon!
EVIDENCE-BASED PRACTICE AND GLACIERS
Since physiotherapy began to research and investigate what it does there has been a slow shift towards using evidence-based interventions, and I mean a really slooooow shift… think glacial speeds. Anyway, this slow adoption of evidence-based treatments has thankfully meant a reduction in less effective treatments and outright woo and quackery being used within the profession. But it also means more people with similar diagnoses are now given similar looking treatments and protocols.
A classic scenario here is someone with Achilles tendinopathy. Ten years ago, they would have had a wide range of treatments from tendon friction massages, calf muscle massages, taping, acupuncture, therapeutic ultrasound, as well as a range of stretches and exercises of the lower leg, and other areas to address so-called dysfunctional movements thought to have caused the pathology.
However, since more research has been conducted into Achilles tendinopathy most are now simply given advice, load management, and specific exercises to load the tendon. Often these exercises are slow, heavy, eccentric, types of exercise to reflect those used in the well-known research trials.
Now don’t get me wrong, I think the removal of the wasteful and outdated treatments is great, I mean friction massages were a bugger for my fingers and thumbs. But, where I think this adoption of evidence based practice is not such a good thing is when treatments are limited to only what the research trials did.
THE INDIVIDUAL WITHIN THE MEAN
Limiting our clinical treatments to exactly replicate what was conducted in research trials fails to recognise an individual’s response to an evidence-based treatment. Only using one particular type, style, or dose of treatment based on a research trial protocol is a failure of evidence-based practice and sound clinical reasoning.
It’s important to remember that a lot of research trials report their findings as an ‘average effect size’. This is often presented with ‘confidence intervals’ to show the spread of that effect over 95% of the subjects in that trial, meaning in very simplistic and not totally accurate terms, the smaller or bigger the spread of the confidence intervals, the smaller or bigger the variation in that treatment’s effects.
Often what happens in research trials is a few individuals get an amazing response from the treatment, some get a good result, others average, some only have minimal effects, and a few get negative and adverse responses. The reasons for this variation are complex and uncertain but often it’s due to differences in subjects’ characteristics such as their health, culture, concerns, beliefs, past experiences, occupational and/or social status.
It can also be due to variations in the clinicians or researchers characteristics who are conducting the trial, such as their training, experience, beliefs, and biases as well. And finally, it can also be due to differences in the application or administering of the treatment such as variations in setting, location, instructions, level of compliance, and timing of the outcome measurement.
All these differences in patient, clinician, and intervention characteristics are termed ‘clinical heterogeneity’ and they all have the potential to significantly confound research results which can lead to inaccurate conclusions being drawn about what does and doesn’t work, and why, and for who. Currently, a lot of healthcare research does a poor job at recognising and/or controlling for clinical heterogeneity and as a consequence, this can and does affect the results and conclusions often made (ref).
SCIENCE IS BROKEN!
Now before some of you rush down to the comments section to tell me “Science is broken” or “I don’t need research to tell me what treatments work” just stop because I am not saying research can’t tell us what treatments do or do not help people. I am just highlighting that often there is a lot of uncertainty in the how much, the why, and the who they can or cannot help.
I am also not saying that we should suddenly ignore research or abandon the scientific method of investigating our treatments, going back to our clinical observations which have consistently been shown to be unreliable and full of biases (ref). What I am saying is that we should recognise the variations in responses to our evidence-based treatments and be more flexible and less specific and constrained in our prescriptions and application of them.
This however is not a green light to go wild and totally off-piste from research-based guidelines, rather to consider tinkering and tailoring with evidence-based treatment parameters and prescriptions more to fit the individual in front of you or based on their response.
Just because one particular type, method, or dose of exercise or even manual therapy has been shown to help individuals with a particular problem or pathology in a randomised controlled trial, this doesn’t mean it helps everyone equally. This means you don’t have to use the same treatments for all people with the same diagnosis, and you can fiddle and adjust the settings, parameters, dosages, and application of a treatment when in the clinic to suit your patients response or situation.
Friction massages suck ass… stop doing them!
Research isn’t perfect but it’s the best method we have to work out what may or may not help our patients, so embrace it!
Look at the effect size of a treatment to get an idea of how much it may help your patients… but don’t get too excited!
Look at the confidence intervals to get an idea of how much variation there may be in that effect!
Look at the subjects in the trial and consider if they reflect your patients.
Be more flexible in your prescription and application of evidence-based treatments
Remember there’s always an individual response buried within a mean effect.
When people are confronted with an argument or criticism against their current position, they tend to challenge the opposing view. This is perfectly normal behaviour and something I, you, and everyone else does. However, what often happens when doing this is we attempt to weaken our oppositions argument by either inadvertently or deliberating misrepresenting it. This is called straw-manning.
A strawman is a common and devious form of argument that gives the impression of refuting an opposing argument by distorting it to make it easier to attack. Using a strawman appears to challenge an opponent’s argument when it actually attacks a version of that argument which an opponent hasn’t stated or doesn’t necessarily support.
I often encounter strawman arguments around my criticisms of manual therapy, such as I advocate a no-touch or hands-off approach, or that I think all manual therapists are malicious or malevolent which is utter nonsense and nothing I have stated or implied at all. Recently two editorials have been published here and here which have further straw-manned many of my arguments and criticisms towards manual therapy and these are now doing the rounds on social media.
In these articles, some of my blogs and opinions have been described as demonising, destructive, and unfairly and inaccurately attacking manual therapy. They go on to explain how this is causing international concern, has adverse consequences to the profession and patients, and how they wish to provide evidence-based information about manual therapy.
Well, that’s also what I want to do and these opening claims in these articles are the first, but by no means the last strawman arguments. Attempting to position my real and valid criticisms about the over complexity, over-promotion, overuse and general ego and elitism around manual therapy as demonising, destructive, or inaccurate is a classic tactic to deflect attention away from the points I am trying to make.
However, I must admit that I’m a little surprised and flattered that the blogs I wrote many years ago are still creating such strong and emotional responses from some of the higher ranks of the manual therapy world. This does give me hope that if I can do this, anyone can, and if more of us continue to question and challenge the nonsense around physiotherapy it can create change for the better.
As these articles are now circulating widely I feel obliged to respond to these allegations of ‘demonisation’ and destruction, and so will in this blog highlight what I consider to be the strawmen arguments and reiterate again what my actual arguments are against manual therapy. I will attempt to keep this short and sweet, and hopefully as calm and rational as I can, but I make no promises.
Strawman No1: Manual Therapy Has No Unique Specific Effects
This first claim is an absolute doozy of a strawman. My actual argument against the specificity of manual therapy is and always has been around the training, beliefs, and ideology that it needs to be administered or applied in a specific way, not that it doesn’t create any physiological effects as claimed.
My argument against the specificity of manual therapy is that it doesn’t matter who, where, how or what type of manual therapy you use, you get similar results based more on the ritual and contextual effects of manual therapy, not its specific or technical skill (ref, ref, ref, ref, ref, ref, ref). My argument against the specificity of manual therapy is that no type or technique needs extensive, extended, or expensive training to do it well.
My argument about specificity is also NOT that manual therapy doesn’t create any neurophysiological effects, rather that it doesn’t create the many structural effects often claimed it does such as repositioning or loosening joints, releasing fascia, or breaking down scar tissue or adhesions (ref, ref, ref, ref)
Finally, all the so-called specific neurophysiological pain modulatory effects described as occurring due to manual therapy in these articles are actually not unique to manual therapy, being seen to also occur during exercise and activity (ref, ref)
Strawman No2: The Use Of Manual Therapy Leads to Patient Reliance, Dependency, and Low Self Efficacy.
I absolutely do believe that some manual therapy techniques given by some manual therapists have the potential to lead some patients’ to dependence, reliance and reduced self-efficacy. I will accept, as I have done many times before, that I have no evidence to support this other than my own anecdotal clinical experiences. I will also admit that this is not unique to manual therapy treatments and can also occur with other treatments such as acupuncture, electrotherapy, taping, and even corrective exercise treatments as well.
However, I regularly see and hear far more patients tell me that they need to get their pelvis pushed back in, or a muscle knot released, or adhesions broken down by a therapist regularly. I have had patients tell me they have seen therapists weekly for years on end having manual therapy treatments in a misguided and misinformed belief that they are essential for a pain-free life and necessary to prevent things from getting worse.
If this is not the definition of creating reliance, dependency, and a loss of self-efficacy then I don’t know what is. As I said I do recognise that this is just my anecdotal experience, and I will say again I have no idea how often this happens, other than I see and hear it a lot.
The strawman presented here is the classic fallacy of “absence of evidence equals evidence of absence”. Now, this quote is often used and abused by nut-jobs and quacks to claim all sorts of stupid and ridiculous things but that doesn’t mean the statement is invalid. Just because something hasn’t been formally investigated or researched doesn’t mean it doesn’t exist.
I believe that well-controlled studies are needed on large samples of patients who routinely see manual therapists for regular treatments, and they are surveyed in an unbiased way about why they attend and what their beliefs and understanding of what these treatments are doing. I’m sure this would highlight that there is indeed a lot of potentially detrimental narratives and behaviours being promoted widely around many manual therapy treatments.
Failing that anyone who thinks that there is no issue here could simply and go onto Instagram and search the hashtags #Physiotherapy #PhysicalTherapy #Chiropractic for about 5-10 minutes to get a sample of some of the utter nonsense and bullshit in and around manual therapy that I witness daily.
Strawman No3: Manual Therapy Provides Short Term Changes Which Do Not Equate to Long Term Changes
The claim in these articles that manual therapy produces short term changes which in turn leads to better long-term outcomes and prognosis is actually not that well supported (ref). However, there is no denying that those who do get quick and dramatic changes in their pain within treatment sessions usually do go on to do well in the long term.
However, what these quick short-term improvements in symptoms most likely highlight is an individual with fewer complications and confounding factors adversely affecting their presentation and natural prognosis, not the effects of the treatment itself (ref). Individuals with fewer medical and psychosocial complications are more likely to have a favourable natural history of their condition regardless of the type of treatment they receive. Often the treatments they receive are unfairly given credit for what is essentially natural history with some placebo and contextual effects sprinkled on top.
There has never been an argument from me that manual therapy cannot quickly reduce symptoms in some people. My argument is simply this is not unique to manual therapy and often affects those with favourable natural histories. My other bigger question is should we be judging our success in how much or how quickly we reduce symptoms in those we see, especially in those with favourable natural histories?
Would it be better to clearly, carefully, and compassionately reassure those we see with mild to moderate pain and favourable natural histories that this is normal and ok to experience and endure for a short period of time. Should we be encouraging more of those we see with MSK pains to tolerate them more rather than reduce and remove them all the time?
Strawman No4: Manual Therapy Techniques Are Based On Outdated, Inappropriate Philosophies That Were Derived To Support Guru’s Theories
Actually, this one isn’t a strawman as it’s not contested in the article, and it’s good to see this finally acknowledged by others in the manual therapy world. The amount of ego, elitism, and arrogance of many of the gurus and others who promote, practise, and teach manual therapy has always been one of my biggest criticisms against it.
The number of therapists who are made to feel worthless, inferior, and unskilled simply because they can’t palpate some fictitious dysfunction or pseudo structural abnormally made up by some half-witted manual therapy egomanic is astounding. If more manual therapy advocates and teachers were less elitist and exclusive and more honest and rational then I’m sure myself and many others would not have as much of an issue with it as we do.
However, I do find it really hypocritical that this article labels this criticism I have of manual therapy as demonising and destructive yet agrees with it.
Strawman No5: Manual Therapists Lack Skills In Communication, Reassurance, And Empathy
This strawman misrepresents my issue on manual therapists communication completely here. It’s not that manual therapists can’t communicate, reassure, or emphasise well with their patients, rather it’s WHAT they communicate and HOW they reassure their patients that’s my concern. Many patients who are told their spine is out of alignment, or their pelvis is unstable, or their muscles are unbalanced are told this by manual therapists taught and trained to believe these things by those gurus and egomaniacs mentioned above to justify using their manual therapy treatments.
Many manual therapists are actually very good and very proficient communicators when they explain to patients why they have pain and how it can be solved. They often display lots of empathy and confidence which adds credibility to their outdated and inaccurate narratives giving patients the reassuring impression that they are in the hands of an expert who knows what’s wrong and how to fix it… usually in 8-12 weekly treatments, with regular monthly maintenance sessions to ensure it doesn’t come back.
Strawman No6: Manual Therapy Does Not Fit Within Value Based Healthcare
You can argue if manual therapy is a high or low-value treatment as much as you like, but this won’t change the fact that currently in the UK, and most of the world, the National Health Services are at breaking point. Public Health Services simply cannot afford the resources to give patients with MSK issues passive treatments to temporarily modulate pain when self-administered hot water bottles or over the counter analgesia can do the same thing.
Decades of underfunding, chronic mismanagement, and a rapidly growing obesity and sedentary epidemic, with an increasingly ill and infirmed population, not to mention the current COVID pandemic, means all healthcare services are stretched. Some difficult and tough decisions need to be made in terms of prioritising what treatments are considered effective and efficient and it is my belief that manual therapy is just not one of them.
Yes ok, the argument in private healthcare settings is different and it may be argued that if an individual has the finances, time, and resources to have manual therapy then there is little issue here. But my argument on the value of manual therapy has always been about public healthcare services.
Strawman No7: Manual Therapy Causes As Much Harm As Help
There is no argument that severe adverse events from manual therapy are rare and most of the transient adverse reactions are also not that common (ref). However, what these articles do not take into account are the potential nocebic and psychological harms that could be occurring due to the outdated and inaccurate narratives and explanations around manual therapy treatments and the burden these may take on some individuals. As mentioned there is no evidence on this, but as also mentioned absence of evidence doesn’t equal evidence of absence.
Strawman No8: We Cant Identify Candidates For Manual Therapy Which Means Techniques Are Unnecessary.
I’m not sure what this last point is really arguing, to be honest. Maybe it’s that Clinical Prediction Rules can help therapists identify which patients are going to respond better to certain types of manual therapy treatment even though they have not been seen to stand the test of time well (ref). Or maybe it’s just that the way to see of manual therapy works on someone is to try it for a few sessions and check the outcomes.
Well as mentioned those that get good responses from manual therapy treatments, most likely would get good responses from any other contextually and placebo rich treatments, or even just time alone due to favourable personal circumstances and natural histories. Again my argument here goes back to the misguided belief and teaching that manual therapy needs to be given to those who have a detailed skilled and specific assessment looking for pseudo dysfunctions and made up structural abnormalities.
So that’s my response and rebuttal to the so-called demonising of manual therapy. As I said I found these articles disappointing and hypocritical that some real and valid criticisms of manual therapy within physiotherapy have been twisted and distorted and perversely demonised.
Although I disagree a lot with this article I recognise that this was written before myself and Chad Cook one of the authors had a face-to-face debate in which we were able to express our positions a lot better away from the limitations of social media, and I would urge you all to watch it to get more of a nuanced view of both sides of the debate here.
I also want to state that when I use the term manual therapists here, I will always precede this with some, most, or many… never all. I know there are some excellent evidence-based manual therapists out there, and I am even fortunate enough to call some of them my friends and colleagues.
I also do not think most manual therapists who fall foul for many of the things discussed here do it knowingly or maliciously, rather they are only following the guidance of what they have been taught and lead to believe by others they trust and respect.
I am also aware that outdated misinformed beliefs, ideas, methods, and treatments are not unique to just the field of manual therapy, with corrective exercise, electrotherapy, dry needling, strength and conditioning, even surgery and medicine all having their fair share of the above. I also want to stress that being taught and hoodwinked by manual therapies training about these things is not a sign of stupidity or ignorance. I myself at the start of my physiotherapy career and during my extensive post graduate manual therapy training was taught and believed many of the outdated, non-sensical, pseudo-scientific things mentioned here.
However, the only way to reduce and untimely remove these is with continued debate, discussion and dare I say a bit of disagreement. This should be welcomed by all but especially by those in positions of respect and authority, and not labelled as demonising, destructive, harmful or unprofessional.
Robust, heated, passionate debate and disagreement should be seen as a sign of a progressive, open-minded, profession, keen to progress and advance. And yes it may not suit everyone and it can be a little frustrating and annoying at times but we all need to recognise that it’s not demonising or destructive.
So my plea to all who may be invested and involved in this profession is to please keep questioning, challenging, debating and disagreeing on all kinds of things, and don’t let those in positions of respect and authority put you off by claiming you are being destructive or demonising. Because if they succeed in shutting down and stopping debate and criticism then we are lost as a profession.
A recent trial looking at the use of steroid injections and exercises for shoulder pain called the GRASP trial has recently been published in The Lancet this month with some interesting results. But yet again, just like there was with the recent SExSI trial there have been some comments and claims thrown around on social media misrepresenting what this trial shows. So this short blog is my attempt to clarify what the GRASP trial does and doesn’t show.
First things first I would like to congratulate all the authors and contributors to this trial as I do recognise doing research like this, as well as this, is both difficult, challenging, and time-consuming. So to get to the conclusion first the GRASP trial which stands for Getting it Right Addressing Shoulder Pain states that progressive exercise is NOT superior to best practice advice and that a steroid injection only offers a small, short-lasting clinically and statically insignificant effect on shoulder pain.
From this conclusion, I have been disappointed to see yet again some physios getting a bit too excited to say how exercise doesn’t help people with shoulder pain, and weaponising this study just as they did with the SExSI trial a few weeks ago to have a dig at my active treatment approach and ethos of ‘you cant go wrong getting strong’. Well, to put this simply as I can these individuals are wrong and misinterpreting and/or misunderstanding what this trial actually shows, usually because they haven’t read it in full just to have a pathetic pop at me instead. So let’s try and help them out a bit.
What is the GRASP?
The GRASP was a multi-centre, pragmatic superiority non-blinded randomised controlled trial, in which 708 patients (average age of around 55) with unilateral non-traumatic sub-acromial shoulder pain, of approx 4 months in duration were randomly allocated to one of 4 treatment conditions. Steroid injection + Best Practice Advice, or No Steroid Injection + Best Practice Advice, or Steroid Injection + Progressive Exercise, or No Steroid + Progressive Exercise.
The first thing which I think has confused and possibly misled a few people about this study is its title and the naming of the treatment groups which I do think at first glance give a false impression that this trial is comparing stand-alone advice with progressive exercises, with or without steroid injections. This is not so.
The ‘Best Practice’ group did have only one session with a physio lasting 1 hour in which they were given advice and education about shoulder pain, reassurance that the pain was not dangerous or harmful or anything serious or sinister. But they were also advised to do progressive exercise 5 x a week following a simple program of exercises with both leaflet and online video support. This group had no formal follow up sessions planned although they could get in contact with a physio if they had any issues.
The ‘Progressive Exercise’ group only differed from the ‘best practice’ group in that they had all of the above but also had up to an additional 5 follow up sessions with a physio over a 4 month period. The ‘progressive exercise’ group just like the ‘best practice’ group still had to do very similar exercises independently themselves 5 x week.
So basically both the ‘best practice’ and ‘progressive exercise’ groups had exactly the same advice, education, and reassurance and both groups were told to exercise 5 x week independently. The only difference is the ‘progressive exercise’ group had the option to attend 5 follow up sessions, which many did not with only around 25% attending the full 6 sessions either due to the physios deeming them fit for discharge or subjects not attending.
Personally, I think these groups would have been better named ‘single session’ and ‘multi session’ not ‘best practice’ and ‘progressive exercise’ as this gives a false impression that only one group had advice and the other group only exercised. In fact, the title of this study also appears to say it compares the effects of advice v progressive exercise on shoulder pain when it clearly doesn’t just do this. This study really compares the effect of single v’s multiple physio appointments in those with shoulder pain, and of course the effect of a single steroid injection.
We also don’t really know if ANY of the groups exercised that much as one of the biggest limitations of this study is that exercise adherence was not strictly monitored. Although the completed exercise rates in this trial were reported in the main paper as being around 90% for the best practice / single session group, and around 75% for the progressive exercise / multi session group they relied on subject self-reporting which often over-estimates adherence.
What I found interesting was in the supplementary files, the individual breakdown of how many subjects reported doing the exercises 5 x week for the first 8 weeks was around 43% for the single session only group, and about 60% for the multi-session group. This dropped to 15% for the single session group, and 18% for the multi session group by 6 months, and at 1 year it was less than 1% in both groups. This clearly shows that a lot of subjects were doing much less or nothing in both groups. We also don’t know how long, how intense, and which exercises the subjects were doing, which again I think is a huge limitation to this study.
So with this in mind, we have to consider that it could be that once educated, reassured, and given some attention and resources, those with shoulder pain improved with time and perhaps some occasional exercise of various intensity, duration, and type. Without a comparative group who were truly only given just advice alone with reassurance to carry on with their usual tasks and activities, we won’t know how much is from the advice or the exercise, but I am will to bet that there is a strong natural history effect here once people with shoulder pain are seen and reassured well.
The other interesting point with the GRASP study was the lack of significant effect of the steroid injection. Steroid shots are given a lot for people with shoulder pain and many are told that it will reduce pain to allow them to move more and do exercises better. And indeed the GRASP trial did show this, in some, for a short period of time.
However, it also shows that steroid injections are not as effective as many think and perhaps not the first thing to reach for in those with shoulder pain. Remember that the average duration of pain for subjects in this trial was 4 months and in terms of sub-acromial shoulder pain that can be classed as still ‘early days’. Personally, I would not often consider recommending a steroid injection for ‘simple’ non-traumatic sub-acromial shoulder pain in the first 6 months, and preferably 12 months.
So there you go a quick review of the GRASP trial which despite some dubious group naming is an excellent trial showing how steroids are not as effective or necessary as many think, and how advice and reassurance and maybe a little bit of exercise for a short period of time can help those with sub-acromial shoulder pain.
Once again to all my special fans out there, this unfortunately for you doesn’t give you any evidence or support that exercise doesn’t help people with shoulder pain, at best you can say it amuses them whilst natural history kicks in, just like most other treatments. However, if you are going to use a treatment to amuse a patient whilst natural history kicks in, why not use one that has a host of positive physiological and psychological benefits rather than all your silly poking, prodding, stabbing, scrapping or sticking them with stuff.
As always thanks for reading and remember, you can’t go wrong getting strong…
Also if you are interested in a fun, engaging and enlightening weekend taking a look at the evidence and how best to assess and manage people with shoulder pain then check out my LIVE+ONLINE and Face-2-Face Shoulder Complex courses here
One of the biggest dilemmas I still have as a physio, even after 20 years of practice, is trying to decide if I should ask someone to avoid things that cause pain or ask them to do the opposite and confront it. Trying to figure out who, when, and why we should ask to avoid or confront pain can be really tricky and difficult as hell to get right.
The first thing to say is there are no right or wrong answers here. Unless you find yourself ALWAYS advising those in pain to stop doing everything that hurts, or you find yourself ALWAYS advising those in pain to ALWAYS do things that cause pain, then you are most definitely doing it wrong.
The facts are not everyone in pain needs to stop doing painful tasks, activities or exercises, but some do! And not everyone in pain needs to start doing painful tasks, activities or exercises, but some do! Some people in pain need advice and guidance to stop doing painful things for a while, others need reassurance and encouragement to start. But who, when, why, how much, and for how long for are where it all gets a little tricky and uncertain.
As much as we try, people just don’t fit into nice neat little boxes or follow rules or guidelines very well. Yet we healthcare clinicians still try to cram people into sub-groups and categories using arbitrary generic factors such as their age, diagnosis, chronicity, and pain levels. But the uncomfortable truth is that no two people in pain are alike, even if they are the same age, have the same diagnosis, or even the same pain levels, yet we assume these factors inform us that we should treat them the same.
When I see clinical guidelines and recommendations stating those with certain ages or certain pathologies should have similar treatments, like all those under 50 years of age with rotator cuff tears should have surgery, or all Achilles tendinopathies should do rehab that causes pain, or all those with lumbar radiculopathy should never do anything that hurts, I get rather frustrated. That’s not to say I never follow these guidelines, it’s just that I don’t think it’s as simple as this when deciding who, when, and why pain is or is not advisable in rehab.
I don’t think deciding ‘who’ should avoid or confront their pain really has that much to do with ‘why’ they have pain. That’s not to say I think diagnosis or pathology isn’t important in our decision making before you all jump on that false dichotomy bandwagon and ride it to the comments section. It always has been, and always will be rule number one to first and foremost assess and screen those in pain for any serious or sinister pathologies.
Rule No 1:
It goes without saying that ALL clinicians should ensure that someone in pain doesn’t have an underlying serious or sinister issue that could cause them further harm or detriment if left untreated. Things like fractures, major soft tissue injuries, tumours, blood clots etc are all essential to check for in those in pain as these need urgent medical treatment and therapy is not the place for them to be.
However, when there are no clear signs or symptoms of any serious or sinister pathology and the diagnosis is more musculoskeletal, but less certain in its specific source, as it often tends to be in most we see in pain, then deciding if I do I or don’t I recommend painful or pain-free tasks or exercises becomes tricker.
These days deciding if I suggest a person in pain does or doesn’t continue on with something that hurts is not only based on their diagnosis, but more on what they have already been doing, how that has made them feel, and how it has gone so far.
No one in pain goes to see a physio immediately, even with acute issues in private settings, usually, there is a period of at least a few days, if not a few weeks or months or longer where they’ve been struggling on with their pain as best as they can before deciding to seek some advice and assistance. Over the years I have realised that it’s not the diagnosis that helps decide if they should or shouldn’t do painful things, it’s more about what they have been doing already with their pain that does.
Now, this is not complex, complicated, rocket science, or any other science for that matter, this is just 20 years of experience in dealing with various people, in various levels of pain, for various different reasons and is a principle so simple its almost embarrassing, but it seems to work… most of the time.
As the father of modern medicine Sir William Osler was famous for saying “listen to your patients they are telling you their diagnosis” I also think listening to your patients also tells you their treatment plan. Asking a few more questions and listening to what someone has already done whilst in pain, why they’ve done that, how that made them feel and most importantly how it has responded pretty much tells you what their management plan should be.
In a nutshell, if someone in pain (with no signs or symptoms of anything serious) tells me they have been mostly continuing on with painful tasks, activities, or sports, pushing into pain regularly and often, and this hasn’t helped or settled things down over a period of time, and this is making them feel upset, anxious, and/or frustrated, I often would suggest they try and do the exact opposite as their treatment. I told ya… not rocket science!
In this situation, I would spend time with this person trying to find ways, means, and strategies to reduce their pain on the movements and tasks that hurt them the most. I would also advise and reassure them that doing something different for a while can be beneficial, and I may even suggest they stop doing something altogether for a period of time.
Rest isn’t Evil
In these days of “can’t go wrong getting strong”, “just load it” and “no pain no gain” it seems that advising someone to stop, rest up, and avoid pain is frowned upon and considered to be bad advice. It isn’t.
I see many people in pain who just continue to push, press, poke and hammer on with painful tasks, activities and exercises, aggravating, irritating and sensitising the shit out of themselves and their tissues in a belief this is beneficial. Sometimes it can be, but often it isn’t.
These individuals regardless of their pathology or diagnosis often need advice, reassurance and sometimes permission to stop doing things that hurt. They also need a lot of distraction and amusement with something else whilst they are avoiding or stopping painful tasks or exercises and so I often give them rehab that works them hard but doesn’t provoke their pain.
I may even suggest they try some manual therapy, taping, quacupuncture or other temporary passive pain modulation treatment thingy if they want to try it (as long as it doesn’t waste too much time, money, or distract them away from other things). I know, I know, I can hear your jaws hitting the floor from here, but my argument against these things has never been they cant help some people, just they shouldn’t be used on everyone, and certainly not in the belief they are skilled, special, or super effective.
Rocket Science Again!
However, if someone in pain tells me they have already stopped doing things that hurt and have avoided their pain in tasks and activities as much as possible for weeks, months, or even longer, and they are worried about making it worse or express concerns about doing harm or damage, and this hasn’t helped settle down or reduce their pain, then I would probably suggest that they need reassurance, encouragement, and motivation to start doing things that hurt a bit… again… its not rocket science.
As Albert Einstein’s said “the definition of insanity is doing the same thing over and over again, but expecting different results” and this is no different with things that hurt. As much as we clinicians don’t like to admit or discuss it, many things that cause pain in musculoskeletal medicine have a very favourable natural history. That is they tend to get better on their own over time thanks to the remarkable adaptable and self-regulating ability of human physiology.
However, when this doesn’t look like it’s happening its often because something is getting in the way of natural history, and yes this can be other pathology and as I’ve already mentioned should be checked for as best as able, but more commonly in my experience, this is due to an individual either avoiding or confronting their pain too much, too often, or too little, for too long.
Our job as clinicians and therapists is therefore very simple, but not very easy. First, we must, to the best of our training, skill, and ability exclude any serious and sinister pathology that could be causing someone persistent pain. Next, we need to identify what, how, and why a person in pain has been dealing with their pain so far, either avoiding or confronting it. Then decide if this is, or is not a successful strategy and if it needs to be continued or more often than not changed to do the opposite. As I said… it really isn’t rocket science!
So it’s the start of a New Year and often it’s a time when many look to change some aspect of their lives, be that exercising more, eating less, or learning a new skill. However, for me, this year my New Years resolutions are that I want to stop going around in circles on social media as much and try to have more productive discussions and debates.
I don’t know about you, but I am tired of having the same old discussions, about the same old issues, with the same old people, with no one prepared to change their views or opinions. As much as these discussions can be useful for others watching and help get different views, ideas and opinions aired, after engaging in these kinds of discussions for years and years I really want to try and move some of them forward, and so I have thought hard, reflected, contemplated, and listened to some advice from others about how I can do this.
Stop Trying To Win
When critical thinking or logical reasoning becomes a weapon, it ceases to be a useful tool. I have realised that if you are using your critical thinking or logical reasoning skills to only win arguments I can guarantee that you will not be using them well.
I have learnt that entering into debates and discussions with the aim of trying to win them is both futile and kind of pathetic. I have realised that no one is keeping count of the debates and arguments you have won except you, and all those that you think you’ve won, you most likely haven’t.
The whole point of entering into any debate or argument is to try and learn something from it, not win it. Having this change in mindset has helped me hugely in the way I interact and engage, or more often, don’t engage with some others. Having this mindset doesn’t mean you can’t stand your ground and fight for your opinions, ideas and position robustly; it just means you don’t assume or expect the other side to change their opinions, ideas or position easily.
Also, when entering into a debate with someone you disagree with, first ensure that you fully understand their position and/or premise. All too often I have found that many who disagree with me do so because they have misunderstood or misinterpreted my position due to only having a small piece of the full story, or a tiny glimpse of my opinions as a whole, especially on the topic of manual therapy, and especially on social media.
Having learned from this happening to me so often, I try to avoid doing it to others by ensuring I have understood their position and arguments as fully as I can before I start to discuss with them further. Doing this can often mean you find out that actually, you don’t need to argue about anything at all.
Stop Engaging As Much
You don’t have to attend every argument you are invited to. Recognising when to pick your debates, arguments, and battles is a key skill to master for your own health and well-being and one I am still working on.
I get a lot of emails, messages, comments, and remarks about various things I write about or post on social media these days, but I don’t respond to most of them. Some people get quite annoyed and frustrated at this, thinking I am aloof, arrogant, or full of myself. I am not.
I have just learnt that after many fruitless, circular discussions that often end up spiralling downwards into personal attacks and other such unpleasantries that mine and the other parties time and energy would have been better spent elsewhere. Recognising when this is happening or likely to happen and then withholding or withdrawing is often in the best interests of everyone.
However, despite withholding comment a lot these days I do still get some usual suspects trying to provoke a reaction out of me by thinly disguising a genuine question or comment as a personal attack or misrepresentation of my opinion. This is usually because they are upset or envious of my position and/or platform.
But again, I have learnt that rather than defend myself against these wassocks they are simply best ignored and avoided completely, and so I often place them on mute for them to moan and whine to themselves and their 23 followers. This is not because I am unable to respond to them, rather because I am unwilling to. And I honestly can’t recommend the mute button on social media enough… It’s a godsend!
Stop Assuming The Worse
Having said that I have also learnt to never assume malevolence in others when ignorance can explain it better. And never assume ignorance when incompetence can explain it better. And never assume incompetence when a simple mistake is the most likely explanation.
I will always give someone I don’t know the benefit of the doubt when they say or post something that I consider inaccurate, misleading, or just plain stupid. Whether you like to admit it or not, we are all too quick to judge others and often assume the worst of them, and I include myself here.
If this last year has taught me anything its that everyone is dealing with their own personal and professional issues that you don’t know about, and if you did they would make your problems look insignificant. So, give more people more room for more mistakes.
Giving people the benefit of the doubt when they say or do stupid shit is crucial these days because it’s so easy to make a simple mistake, misspeak or just be mislead or misinformed by others. However, if the usual suspects do keep on doing or saying stupid shit repeatedly despite others comments and critique then, by all means, call them out on it
Stop Spreading Bullshit
The last and most important point I want to make about social media discussions is about calling out pseudo-science, alternative facts, or straight-up bullshit. Despite some claiming otherwise, all healthcare professionals have a duty and responsibility to highlight bullshit circulating on social media about health, disease, pain and treatments whenever we see it.
Calling bullshit is essential for our profession to progress, but also to help protect our patients and the public from misinformation and making poor choices. However, there is no doubt that calling bullshit is both difficult and challenging and it has to be done appropriately, responsibly, and respectfully.
The first thing we can all do to help reduce the amount of bullshit circulating on social media is to, and I can’t emphasize this enough is… STOP PRODUCING AND SHARING BULLSHIT OURSELVES.
If you are going to call bullshit on others, being full of shit yourself is about as hypocritical as it comes, and I hate hypocrites.
I have learnt that carelessly calling bullshit on others whilst being guilty of it myself is a quick way to make enemies of strangers, and strangers of friends.
So, again I don’t think I can emphasize this enough… CHECK YOUR FACTS AND SOURCES THOROUGHLY before clicking that retweet/share/like button!
Just because that high impact journal publishes a paper showing your favourite type of exercise outperforms something else, doesn’t mean its worthy of sharing with others when you check the study design and find is about as robust as a chocolate teapot. Or just because that well-respected media source quotes some statistics on the latest treatment doesn’t mean they have interpreted them correctly or accurately.
Also, just because some Insta-Face-Tweet-book guru with a gazillion followers does something fancy or flashy on social media doesn’t mean its effective or evidence based. And conversely, just because that eminent Professor has written a pithy editorial highlighting the flaws in some social media gurus thinking doesn’t mean their thoughts or opinions are anymore valid, correct, or accurate.
The rate at which bullshit spreads on social media these days is both staggering and frightening, and I know full well that I have, at times, been an unwilling and unknowing part of it. However, if we all try to work a little bit harder, to think a little bit more, and check our sources and facts a little bit better we can help reduce this.
So there we go, a few New Year’s resolutions that are a little different from the usual exercise more / eat less. I am hoping to stick to these as best as I can through 2021 and beyond but like most New Year’s resolutions, I’m sure there will be some relapses and setbacks along the way, so #BeKind!
However, with some patience and perseverance, I’m sure that we all can improve our social media discussions and behaviours a little bit more. And on that note, I would just like to wish you all a happy and healthy 2021 and don’t forget about that mute button… honestly use it more…. You won’t regret it!
I listened to an interesting podcast on the ‘myths of manual therapy’ recently in which I was referred to as a ‘well-known Twitter personality’ who has been misleading therapists with my blogs on manual therapy. Well, of course, I strongly disagree with this… I actually consider myself more as an Instagram Guru than a Twitter personality these days.
But in all seriousness, I do have some points I want to raise about some of the claims made in this podcast with Chad Cook about a blog he wrote in German about the myths of manual therapy. First things first, despite disagreeing with Chad a lot around the topic of manual therapy, I agree with him a lot on other things and have no personal ‘beef’ with him, despite his digs, occasional character assassinations, and misrepresentations of my views on manual therapy that I see and hear from him .
However, putting all that to one side and for the sake of progress I would like to talk about four points Chad brings up in this short podcast. The first is that manual therapy adds value and improves patients’ experiences. Second is that self-efficacy is a deeply rooted and difficult trait to change. Third, there is no evidence that manual therapy causes dependence in patients. And finally, the use of manual therapy helps identify patients who have better outcomes.
Does manual therapy improve patients’ experiences?
I certainly agree with Chad when he says at the beginning of this podcast patient experiences are strongly linked with their outcomes. However, I strongly disagree when he says that patients experience more value with ‘hands-on’ and less value with ‘hands-off’ approaches.
This is because the experience and value a patient feels they get from any healthcare appointment is not just about what treatments they get, more about how they were treated.
You simply don’t magically and miraculously improve a patients experience of a healthcare appointment by touching them. You improve a patients experience of an appointment by listening, validating, empathising, explaining, reassuring, educating, and planning with them. If you don’t do any of the above well it really doesn’t matter if you touch them or not.
This persistent argument of improving patients experiences or meeting their expectation as justification for using manual therapy is, in my opinion, a rather lame and flimsy one. First because its been well documented that using patient satisfaction is a pretty ineffective way to measure a treatments efficacy or effectiveness (ref, ref, ref).
But also because despite all the criticisms around manual therapy no one has actually said don’t touch patients. In all my constant criticisms against manual therapy I have NEVER said anywhere at any time don’t touch patients. Just the opposite in fact.
I have written blogs, posted thoughts, opinions and many papers highlighting the importance and power of touch to patients to examine, reassure, facilitate, and encourage them.
There has never been any argument from me that using touch as a clinician is important and helps improve a patients experiences, usually by giving them the reassurance they have been fully examined and their issues are taken seriously. But this still doesn’t mean you have to use manual therapy treatments.
Is self-efficacy deeply rooted and difficult to change?
In the podcast, Chad also mentions that self-efficacy is a deeply rooted trait and that ‘it’s extremely difficult to change’. He also says that some (and I assume he is again referring to me here) clearly don’t understand it and haven’t read much about self-efficacy. Well, Chad, I’m no self-efficacy expert but I have read enough to think you are mistaken here.
The first issue is what does Chad mean by self-efficacy is deeply rooted. Self-efficacy of what? Self-efficacy on its own is not a thing as discussed by my mate Ben Cormack here. Self-efficacy is an individual’s judgement of their capability to do a specific task in a specific situation, therefore it is highly context dependant (ref).
For example, currently, I have very high ‘deadlift’ self-efficacy meaning I feel very capable to pick heavy things off the floor in a gym. However, this doesn’t mean I will have the same high levels of deadlift self-efficacy if I have low back pain.
Also, I currently have low ‘car maintenance’ self-efficacy meaning I don’t have a clue how to service my car these days with all its technology and gadgets. This means I also have very low ‘I’m broken down on the side of motorway’ self-efficacy. However, when I arrange some roadside assistance I very quickly change my low ‘I’m broken down on the side of the motorway’ self-efficacy to high.
So when Chad says self-efficacy is a deeply rooted trait and extremely hard to change I disagree, because it depends hugely on what the task and situation is.
When it comes to patient’s we usually refer to their pain self-efficacy. But again, what type of pain are we talking about? Back, shoulder, hip, little finger? Acute, chronic, mild, moderate, or severe? Because when it comes to pain self-efficacy different locations, types, and severity of pain can create different levels of self-efficacy in the same individual.
For example, a patient with chronic low back pain may have very low self-efficacy to bend forward and pick up a kettlebell during their physio session yet have much higher self-efficacy to bend forward and pick up their child up at home. What appears to be low and deeply rooted in one context may not be so much in another.
A final point I want to make in regard to self-efficacy is that it has been found to be a mediating factor in low back pain and disability (ref). However, we don’t actually have much evidence to show that improving self-efficacy is what helps reduce pain or disability, or that our interventions change it, which leads me nicely onto my third point.
Does manual therapy create dependence in patients?
In the podcast, Chad mentions that he has searched and scoured the evidence base in both a scoping and systematic way looking for any evidence of manual therapy creating dependence in patients and found none. From this, it appears, and I may be mistaken here, that he implies manual therapy doesn’t create dependence in patients.
This is a logical fallacy of mistaking an absence of evidence as evidence of absence, which is a saying often abused by quacks trying to justify woo. But putting aside the crystal healers and chakra cleansers Chad can NOT say that just because there is no evidence of manual therapy creating dependence in patients that it doesn’t occur or that can’t do this.
I must admit it was surprising and frustrating for me that my own efforts in searching the evidence base have also been unable to find any papers that show patients can become dependent on certain treatments such as manual therapy. This is because it goes against my 20+ years of front-line clinical experience of hearing and seeing 100’s if not 1000’s of patients demonstrating dependency on all forms of massage, manipulations, needles, injections, taping, and electrotherapy treatments.
But on further thought its not really that surprising, as to do this type of research I think would be extremely challenging and difficult to do well, and probably why no one has tried yet. The first issue is in trying to design a study looking for dependence on manual therapy or other passive treatments that is ethical, and as well controlled as possible to avoid the many possible confounding factors such as clinician and researcher equipoise and bias, but also trying to work out how to rate or judge dependence.
I don’t know about you but in my experience those who are most dependant on things tend to not be aware, recognise, or admit that they are dependent on things. Therefore, simply asking patients do you think you are dependent on X won’t work and asking clinicians the same will also have issues.
I do agree with points raised in the podcast that most patients are not stupid and don’t become dependent simply or easily. However, patients are often very trusting towards clinicians and I have seen far too many clever and intelligent people tell me that they go and see ‘their guy’ 5-6 times a year to get their pelvis put back in, or that muscle knot rubbed out for 5, 10 even 20+ years because they like, trust, and believe them to know it happens.
Will this ever be demonstrated in the evidence? I don’t know! Will this ever change? I don’t know! All I do know is I hear and see patients regularly receiving unnecessary treatments due to some false, misleading narrative given ignorantly or deliberately by some therapists providing them for payment.
Does manual therapy improve outcomes?
The final point I want to discuss is Chads points he raises around within and between session changes, that is patients who feel immediate improvements (within session) and those who feel delayed improvements (between session).
Chad discusses how there is evidence to show patients who have immediate within session changes have a small to moderate likelihood for good long-term outcomes, and those who have positive between session changes have very strong predictions of good outcomes in the long term. From this, and again I may have misinterpreted this, it appears Chad implies that manual therapy can therefore help improve patient’s outcomes.
However, I have some questions here. The first is couldn’t both these within and between session changes just be seen in patients with favourable natural histories improving regardless of the treatments they receive? I mean just because a patient gets some manual therapy and then displays some improvement next session doesn’t mean the manual therapy was the cause of that.
It could be those that have good within or between session improvements with manual therapy, or any other treatment, may just be those with low-risk factors, and conditions with favourable natural histories improving regardless.
Also, I maybe a little slow here but is it really that surprising that patients who show signs of improvement, tend to improve more than those who don’t show signs of improvement? Or am I missing something a bit deeper here with these studies?
So that’s my review of Chad’s recent podcast on his German blog in which I get a brief mention… I think. It’s a shame its not available in English as I would like to read it to make sure I am not misrepresenting Chads positions on his myth-busting of manual therapy because I know how annoying and frustrating that can be.
Now just in case, anyone is still unclear on what my position on manual therapy is I will lay it out once more. I believe that most manual therapy used in musculoskeletal therapy is overcomplicated, over-hyped, and overused. It is surrounded by a tonne of ego, elitism, and some absolute throbbers full of bluff and bravado who teach it, with ignorant, ill-informed, misleading and potentially harmful narratives about what it does and how it does it.
I think manual therapy is a low-value treatment because of its small, unreliable, short-lasting effects making it not worth the time, energy, and costs to provide it. This is not to say manual therapy doesn’t do anything for anyone, rather, that its best provided by those who can offer it at more reasonable costs to those who have a low risk of it not distracting them away from other more important interventions for their pain or disability.
First things first, a disclaimer, I earn an income from teaching a course on shoulder assessment and rehab, as well as an online education platform which some individuals like to highlight in an effort to embarrass or shame me or invalidate my views on physiotherapy education and post graduate courses. They don’t do either.
I’ve been teaching physios for well over 10 years now and although I’m still a clinician at heart working both in the NHS and private practice, I do now also consider myself an educator, a teacher, a sage from a stage, a guide from the side, or whatever else you want to call someone who attempts to impart knowledge onto others, and I’m very proud of it. Anyway, I have skin the game in this argument and so of course this will affects my views.
Well meaning but misguided
The main premise of the editorial is “journals are well-placed to shape practice if they choose to take an active role in knowledge translation by accrediting quality courses.”. This, in my opinion, is well-meaning but misguided in thinking accrediting continuing education courses will improve the quality of them.
Most of my thoughts on this can be neatly summarized by my mate Erik Meria who did a very nice thread on this here.
I understand and share the authors desire to improve the quality of continuing education within the profession, and agree with them when they say many courses are ‘questionable’ in quality and content. For example, a quick look through a well-known course provider’s list finds courses on quackery such as electro-dry needling, cupping, even myofascial release with sink plungers.
However, having journal editors accredit quality courses will NOT help reduce the number of these bad and questionable courses and could in fact reduce the number of good quality courses even more. Shitty courses will not disappear or be any less popular just because there is an accreditation scheme by a few journals.
The simple reason questionable and dubious courses thrive is due to the demand for them. Many therapists just do not have the scientific literacy or critical thinking skills to recognise that these courses are peddling placebos and snake oil under pseudoscience and flimsy excuses of emerging evidence.
Instead of trying to regulate and accredit those who produce shitty courses, I think we should focus more on improving the critical thinking skills of those who go on shitty courses. Once therapists can start to see that these shitty courses are pseudoscience and quackery that wastes time, money, and don’t actually help patients much at all the better.
The other issue is that journal editors are the best people to judge what is and what isn’t a quality post-graduate course. I appreciate that many journal editors are smart, intelligent people, and often have good knowledge of the evidence base. Although from some limited personal experience with some journal editors I also know this isn’t guaranteed.
However, being a journal editor is no measure of being a good judge of the quality of a course or another’s ability to teach well. A good high-quality course is at least about the best quality evidence available but this is not sufficient for a good course, trust me I know having been on many courses presenting the latest evidence but in a dull, boring, and instantly forgettable way.
There are many other factors that make for a good learning experience other than just the evidence presented. Presentation style, graphics and visuals, speaker enthusiasm and personality, practical demonstrations etc, the list goes on and on. All these factors are essential for a quality course, not just the reference list.
Conflicts of Interest
The other concern I have with journal editors accrediting others’ courses will be their bias and vested interests affecting their judgement. And I’m not just talking about financial conflicts of interest that the editorial mentioned.
There are many other conflicts of interest other than financial to also consider. For example, I know damn well that many journal editors would not approve or accredit my course due to previous professional disagreements and personal dislike towards me, as well as issues they have with my social media platform, its reach, and my own views and opinions.
Don’t get me wrong I would gladly and confidently submit my course for scrutiny and review to anyone if I thought it would be truly fair and impartial. However, from previous experience of dealing with editors and peer reviewers who reject things on nothing more than personal dislike I know it often won’t be reviewed either fairly or unbiasedly.
I also know from past experience that handing your materials over to those to review and accredit it, who teach similar courses and subjects as you, leaves your work open to being copied and plagiarised as I have seen personally happen to me a few times to my utter frustration and dismay.
So, in summary, I agree with the editorial that shitty courses are a problem in physio, but I disagree that journals policing and accrediting post-graduate courses is the solution. Instead, improving therapists levels of critical thinking and decision-making is the way forward here and then it comes down to the basic economics of removing the demand, and the supply will cease.
As always thanks for reading, and be sure to check out my upcoming non-accreditted but ‘high quality’ evidence-based Painful Shoulder courses below!
I have a confession to make. I don’t use that many outcome measures with my patients! I know admitting this may be shocking, almost sacrilegious to some evidence-based clinicians, and it may leave me open to some criticism. But before you do, hear me out as to why I think outcome measures don’t help most patients or therapists that use them.
Outcome measures are simply something that quantifies and records a dependent variable, such as pain or function, that is being affected by an independent variable such as treatment and interventions. There are literally hundreds of outcome measures available in musculoskeletal medicine and they come in all different variations and varieties
There is no doubt that outcome measures have helped healthcare move away from eminence based practice which relied upon biased and unreliable observations and personal opinions of what clinicians thought did or did not work, towards more reliable and unbiased ways of recording what does or doesn’t work. However, I think many outcome measures in clinical practice today are not used well and offer very little for patients and clinicians.
The Early Days
From the start of my career as a physio, I was taught to use all varieties and variations of outcome measures with my patients to ‘prove’ the effectiveness of my interventions and justify what I was doing. And that’s exactly what I did for many many years, but these days I hardly use any outcome measures.
You may be thinking, how do I know if what I am doing is effective or working. You may also be thinking that I’m a huge hypocrite for always going on about the need for more evidence in physiotherapy, yet here I am saying I don’t collect evidence of my interventions with my patients.
Well, your right this is contradictory behaviour, and if I am being honest this is not the first time I have been a big old hot mess of contradiction. I do think the physio profession desperately needs more evidence to demonstrate what it does or doesn’t do is effective, I just don’t think my day to day collection of outcome measures with my patients helps achieve this in any way shape or form.
I don’t think most outcome measures are useful for most clinicians in normal everyday clinical encounters for a number of reasons. First, a lot of the data collected with many outcome measures is rarely collated, analysed, or used for anything useful. Secondly, most outcome measures create frustration and unnecessary barriers between patients and clinicians. And lastly, outcome measures don’t actually measure what many think they are measuring.
Unless involved in research or a clinical trial most data obtained on outcome measures is not used for anything meaningful. Most data collected in outcome measures is collected by clinicians on orders of their managers, insurance companies, or other professional organisations often for the sake of paperwork purposes, legal documentation, or just to be seen to be doing the right thing.
Outcome measure scores mean very little to patients and most outcome scores are not used to check if patients are actually getting better. Instead, a lot of outcome measure data is used to rate and assess if clinicians are effective rather than if patients are improving.
This is not what outcome measures are designed for. I have been appraised many times throughout my career by managers checking my patient’s outcome scores. I have even been given specific outcome measure targets to achieve in some clinics I’ve worked at.
There’s an old saying that goes “as soon as a measure becomes a target, it ceases to be a good measure”. This is because when a measure becomes a target our biases and errors increase during the recording of the measurements as we attempt to obtain the target.
This affects both the reliability and accuracy of the outcome measure and gives us skewed perceptions and results of treatments and clinicians’ effectiveness. There is also another saying that goes “what is mismeasured is mismanaged”. Meaning that misusing outcome measures to rate clinicians rather than patients often leads to patients being mismanaged.
They Don’t Do What You Think They Do
Many clinicians collect outcome measures in the mistaken belief that they prove the ‘effectiveness’ of their treatments and interventions. They don’t. Outcome measures measure patients’ outcomes not the effects of treatments or interventions given to them. That sounds bloody confusing so let me clarify it a little more.
Basically, there are many things that can affect a patient’s outcome other than just the treatment they receive. Things like time, beliefs, expectations, reassurance, placebo, and many other factors which I have discussed before. Outcome measures therefore also ‘measure’ the effects of these things as well, not just the effects of treatments received.
A common misunderstanding made by many clinicians is that when an outcome measure score improves or worsens it must mean their treatment was the cause of this. It doesn’t. Just because a patient improves, or deteriorates after treatment it doesn’t mean it was because of the treatment, as patients can and do improve and deteriorate despite the treatment they receive. (ref)
Many also misinterpret patients’ responses recorded in outcome measures. For example, the Pain Self Efficacy Questionnaire (PSEQ) is often used to assess patients’ fear of movement when doing tasks when in pain. However, the Pain Self Efficacy Questionnaire only measures a patient’s confidence to do the tasks described in the questionnaire, and this doesn’t transfer well to other tasks.
Just because a patient scores high in self-efficacy to do household chores on the PSEQ when they have back pain, this doesn’t mean they will have high levels of self-efficacy to do kettlebell swings or bird-dog exercises during their rehab. It’s important to remember that outcome measures only measure what the outcome measure is measuring, they do not inform us about other things.
Another factor to consider is that patients may fill out outcome measures based on information they have to recall from the past which may be poor and inaccurate. They may also answer questions in a specific way due to concerns about the effects or impact their answers may have on future treatments or interactions with clinicians.
Outcome measures also create a lot of unnecessary barriers to patient-clinician communication and therapeutic relationship building. I often see a lot of confusion, frustration, and apathy in patients as they struggle to fill out questionnaires and answer a long list of boring meaningless questions, or try to give a simple single word or numerical score on something that is complex and complicated.
For example, does the number 7 really explain and describe the severity, intensity or frequency of an individual’s experience of back pain? Does ‘sometimes’ or ‘occasionally’ on a tick box really convey the frustration and anxiety someone has with their sleep being disturbed?
Some outcome measures can also take 15-20 minutes to complete, and often the questions mean very little to those filling them out. A classic example I come across is with the Oxford Shoulder Score (OSS) which I have to use a lot in my current role. There is a question in this about the level of difficulty combing or washing hair which always gets bald men rather annoyed and perplexed!
Outcome measures can not and do not capture the complexity or uniqueness of individuals’ pain and disability well, yet many clinicians use these measures to identify patients’ problems and disabilities instead of actually asking them what their actual problems and disabilities are.
Just because someone says they have a lot of difficulty washing their hair, or a lot of back pain when doing household chores on a questionnaire, this does not mean these are meaningful goals for them to achieve. They may be far more concerned about not being able to play with their kids, sleep through the night, or do their job far more than they are concerned about their doing their hair or household chores.
Not Completely Useless
However, although I’ve been very critical of outcome measures and think they are not used well and offer little for most, I don’t want you to think I am completely dismissing them, or that I don’t collect any information from my patients at all.
As I have said I think most outcome measures are often best suited for research purposes and clinical trials. However, there is one outcome measure that I use regularly with a lot of my patients which is validated, quick, and simple, but more importantly, doesn’t create any unnecessary barriers or frustrations with my patients, and this is the Patient-Specific Functional Score (PSFS).
The PSFS involves asking the patient what are 1 to 3 things that are important and meaningful to them that they are having difficulty with currently because of their pain or issues now. This could be anything from brushing their hair to playing tiddlywinks, it doesn’t matter, it’s up to the patient to decide, not a bloody questionnaire.
They then rate how difficult it is for them to do these things on a simple scale from 0 to 10, with 0 being impossible, and 10 being no problem at all. These tasks are then reassessed at various time points throughout their treatment to see how progress is or is not going. I find this outcome measure to be one of the most simple, meaningful, and least obtrusive ones out there and one that I think should be used often in clinical practice.
So there you go that’s my quick look at why I think many outcome measures suck in physio. To summarise…
* Don’t use outcome measures to measure a clinician’s effectiveness
* Don’t think outcome measures only measure a treatment’s effectiveness
* Don’t ask bald men to fill out the Oxford Shoulder Score
* Do use the Patient-Specific Functional Score more
It’s been a tough few weeks for exercise in healthcare both on social media and in the research. A recent systematic review has shown it provides little to no benefit for acute low back pain. Then a very interesting blog called it ‘snake oil’ and a ‘dirty word’. And finally, a discussion on twitter questioned my favourite slogan of ‘you can’t go wrong getting strong’.
It’s fair to say that exercise, as a treatment for pain and disability, has a lot of critics, questions, and uncertainties around its efficacy and effectiveness. And although I am, and always will be, a very ‘strong’ advocate for exercise within healthcare I have to reflect and ask myself why do I use it as a treatment so much?
If I am being brutally honest I use exercise with most of my patients because I am biased towards it, but also because I think it’s expected and assumed by patients that’s what us physios should do. There is a very strong tradition and culture that physios give out exercises when you go to see them for pains and problems, just like doctors give out medications, chiros give out back cracks, and surgeons slice and dice.
Although I think exercise has many benefits and is one of the most evidence-based and supported treatments we physios have, I think it’s often over-complicated, but under-promoted, however, I don’t think it’s sufficient to help many in pain and disability improve and I don’t think many patients actually ‘need’ it as a treatment.
Now before you all go lose your minds and head down to the comments section to call me a hypocrite or express disgust, disappointment, or just to gloat and say ‘I told you so’ keep reading on a little bit longer.
Let me explain!
I think we can all agree that all pain and disability is individual, complex, and multifactorial. From the enigma that is non-specific low back pain, to something as ‘simple’ as an Achilles tendinopathy all aches and pains can confuse and confound us, regardless of the cause of the severity of pain or level of disability we really just don’t know what is needed to be addressed to help them.
For example, when someone has low back or Achilles pain do we need to ask them to move more or less? Do we need to increase their strength, power, or endurance? Do we need to improve their knowledge, confidence, or pain self-efficacy? Maybe they just need to lose some weight, stop smoking, sleep a bit better, and relax more??? The factors to consider are almost endless.
Now there are some conditions where we do have a better understanding of what needs to be addressed more to help some improve, for example after an ACLR ‘it’s the quad’ as my mate Erik Meira would immediately say. But for many other pains and disabilities, the list of factors and variables is long and complex.
But to think that addressing just one factor will be sufficient is both naive and ignorant, even Erik reluctantly admits that it is actually more than just the quad to return to play after an ACLR. However, I think many therapists are failing with their exercise treatments because of their limited and reductionist way of thinking about it and in their use of it.
Using exercise monosyllabically just to increase someone’s strength, power, or even confidence when they have complex, multifactorial issues is only going to partially help or simply just fail. Working with patients with pain and disability we can NOT use exercise like S&C coaches working with athletes who often only have simple single factors to address such as strength, power, or endurance.
You’re not an S&C Coach!
It really is great to see more and more physios improving their exercise understanding and prescription skills and something I hope continues. However, I am concerned that more and more physios are using exercises with their patients like S&C coaches use them with their athletes, replacing poor old Mrs Miggins 3×10 shitty banded external rotations for 5×5 90% 1RM overhead KB presses at a tempo of 3301, coz S&C gainzzz baaaby!
Don’t get me wrong I think it’s great to try and get as many patients, even Mrs Miggins as strong and powerful as possible using S&C principles, but if you think it’s only about increasing strength or power for pain and disability then you and your patients are going to be disappointed.
S&C has become a bit of buzz word recently in rehab and many S&C coaches are training physios and are being revered like messiahs and the second coming, here to save physios from the error of their ways with their big biceps, fancy periodisation programmes, and 0-2 reps in reserve.
Don’t get me wrong I’m glad that physios are learning better exercise prescription from S&C coaches at last. But like I said earlier I think many physios give out exercises because it’s expected that’s what they should do rather than thinking that’s what they should do.
Also, physios often give exercises without involving the patients into the process because it’s 1) believed they should know best, 2) justifies their existence and fees, and 3) helps with the illusion of being more skilled and specific.
This is a mistake and something that I think needs a monumental shift in culture and training. To make exercise more successful we need a joint and collaborative approach working alongside patients expectations, beliefs and abilities, helping to guide and motivate them accordingly.
However, much as I hate to admit this, the uncomfortable truth is that most things we physios see tends to have a favourable natural history and often gets better with nothing more than time. Basically meaning that they get better no matter what exercises we give or what other treatments we do or don’t do with them. (ref, ref, ref)
This is a hard pill to swallow and accept for many physios and other therapists, especially after spending years of hard work and dedicated study learning about the complexity of human anatomy, physiology, and pathology and its treatment. To be told that it doesn’t really matter what you do with your patients because they will get better, or won’t regardless, is both a slap in the face and kick in the ego-testicles.
And I get it, I still hate that awkward feeling even after 20 years of practice of assessing a patient fully, checking that there is nothing serious or sinister, realising their issues, pain, and disability will most likely improve with little more than time, reassurance, and simple advice to keep moving as much as they can. This makes you feel a little embarrassed and useless inside, like your not doing enough to justify your fees, that your skills, efforts and dedication in helping others is worth little and actually not that important or needed.
So to mask these feelings I think a lot of us tend to over conflate and over complicate what we do and say, hoping to fill that awkward gap of waiting for natural history to kick in by over-treating and doing more than really is needed. Be that with some fancy advice, education, manual therapy, joint manips, colourful tape, cupping, scrapping tools, pointy needles, machines that go bing, or fancier exercises.
Still use it!
However, although I have been quite critical of exercise highlighting its small effects on pain, and how it doesn’t outperform placebo, and how I think most patients don’t actually ‘need it’ to get better. I still strongly advocate and recommend it with all the patients I see.
Yeah, I know what a hypocrite right, but hear me out. Although I don’t think formal specific exercise is needed for many pains and disability, I do think formal specific exercise is needed for general health and well being.
Now I have seen a lot of debate and discussion recently on this topic with some saying healthcare clinicians shouldn’t be so dogmatic, prescriptive, or harsh with their exercise recommendations. That they need to understand and appreciate not everyone enjoys or likes exercise and instead prefers general activity and other types of movement, and these are just as important for health and well being.
But I think these discussions are confusing two very different things, that is exercise and activity, and although used interchangeably they are not the same. It’s also not that one is better than another, its that BOTH are essential for an individuals health and well being, and BOTH should be encouraged and advocated more.
Go hard or go home!
General recreational activity and other lower-intensity movements are great and an essential component for an individuals health and well being. But no matter how much you wriggle, worm, contort or twist it you just can not escape from the harsh facts that regular intense, robust, difficult, awkward, even painful exercise is ALSO essential for and individuals health and well being. (ref, ref)
As much as movement matters, so does intensity, and to think you can go through life at a constant low intensity without needing to challenge your body and mind hard and often is both misguided and mistaken (ref). Our bodies and minds respond to the stresses and pressures they are exposed to, toughening and hardening them. Without stress and pressure, there is no robustness or resilence.
Now, I have also seen some comments from some acupuncturists with delusions of grandeur who think that we should only be focusing on treating an individuals pain and disability, not using exercise for health, well being, robustness and resilience. They also claim that using the secondary benefits of exercise as a justification for its treatment for pain and disability is just an excuse.
Well, I think these are pathetic, asinine, narrow-minded comments used by some clinicians more interested in their own agendas of trying to justify their use of passive interventions for helping pain and disability.
I see this a lot recently with clinicians and researchers trying to justify the use of things like manual therapy or acupuncture by comparing their pain-reducing effects to those of exercise. This is like trying to justify the nutritional benefits of doughnuts by comparing their effects on satisfaction to sticks of broccoli. They’re just not comparable.
Exercise and pain
As I’ve already mentioned exercise doesn’t demonstrate strong effects for most pains or disabilities, but that doesn’t mean it doesn’t reduce pain at all. Exercise has been shown to reduce pain via various different mechanisms, such as endogenous opioid analgesia, diffuse noxious inhibitory control, habituation, conditioned pain modulation, and expectancy violation.
The issue is that most studies are small, with a high risk of bias, and normally done on healthy individuals (ref). I am well aware that exercise for pain is not a panacea and its effects on pain can be similar to most other treatments such as analgesia, injections, acupuncture, manipulations, massage etc.
However, if I am going to choose a treatment for someone’s pain and or disability out of all those that are available that all have similar effects, then I am far more comfortable choosing one that has some well known, well researched, positive secondary effects on an individuals health and well being. This is not ‘excuse based practice’, this is ‘exercise-based practice’.
My blogs are a lot like buses, you wait for ages then two appear together. I was not planning to write another blog so soon after my last one, but, I was made aware of a recently published editorial and response letter discussing a ‘puerile anti manual therapy trend’ and ‘self-perceived social media experts’ that I have been referenced in. So I thought a reply was warranted.
Another reason my blogs are a bit like buses is just like buses have passengers who want to go somewhere, it’s the driver who decides what route, how fast, and what potholes it goes over. So as ‘passengers’ of my blog, I would suggest holding on tightly because this bus is going down some rough roads. If you think this is not the right bus for you then I would suggest getting off now.
Been Here Before
The first thing to say is that I have been here many, many, many times before responding to these kinds of pathetic whiney publications from the higher ranks of the manual therapy community, moaning about those who question and challenge its use and usefulness.
I was in two minds whether to give these silly articles any time at all as I really don’t think they are worth it. They are published in a low-value journal, written very poorly, and don’t construct much of an argument at all. I also don’t know the authors and so don’t really care what they think of me or my blogs.
However, as I have been referenced I thought a response from me may get the discussions around the efficacy and effectiveness of manual therapy going again, and it gives me another opportunity to have another rant about the egos and elitism of the manual therapy gurus which is something I love to do.
Insecurity and Desperation
So my first thought after reading these ‘glorified blogs’ is that they scream of insecurity and desperation from those whose identities and careers are deeply embedded within their manual therapy interventions. If these authors are that concerned to reference a blog I wrote a few years ago as a significant threat to manual therapy they must be standing on some very thin ice, or I am massively underestimating the influence of my blogs.
These editorials are nothing more than weak appeals to antiquity and authority wrapped up in a very thin disguise of professional concern. They are basically saying that manual therapy has been around for a long time so therefore it must be good, and as a profession, we have always used it so therefore we should continue to do so.
It’s honestly some of the worst justification for manual therapy I have ever read. They even try to use the current chronic pain epidemic and opioid crisis as grounds for the continued use of manual therapy. What they don’t provide, however, are any plausible arguments or evidence that manual therapy can do anything about these issues.
Conflicts of Interest
When I see these kinds of editorial, papers, and reactions it often leads me to suspect that there may be some personal bias and conflicts of interests camouflaged as ‘professional concern’. So I did some background investigation into the authors, who I will state again I have had no interaction with at all, and do not know in any way. I found that the lead author and a co-author are both faculty members of well known manual therapy institutions and they both teach post-graduate manual therapy continuing education courses, therefore earn incomes from manual therapy.
Now there is absolutely nothing wrong with this, but it is a clear conflict of interest and so should be clearly disclosed to the readers of this article, which it is not. In fact, the authors declare no conflict of interest (see image below) which is another reason why I think this journal and editorial board are poor, it literally took me 2 minutes to find this out.
Anyway, the authors of this piece continue to moan away in that usual passive-aggressive academical way, about how the profession is in danger of losing its identity if it abandons manual therapy blah blah blah. They also appear to blame ‘charismatic presenters’ and accuse those who are ‘anti manual therapy’ of being ill-informed and biased. Which I find hugely hypocritical especially in light of them not declaring their own biases.
Exercise Not Manual Therapy
Also, despite what they claim in this editorial the modern physiotherapy profession was NOT born from manual therapy but from EXERCISE. One of the earliest documented origins of physiotherapy as a profession dates back to Per Henrik Ling from Sweden who founded the Royal Central Institute of Gymnastics in 1813 (ref). The UK physiotherapy profession evolved after the first world war to help aid wounded soldiers back to function, and originally we’re called remedial gymnasts (ref). Yes, they used massage and other things, but their foundation was always exercise.
But putting that aside the physiotherapy profession is simply NOT defined by ANY intervention, be that manual therapy or exercise. Just as medicine is NOT defined by any one drug or surgery by any one procedure. One of the biggest reasons I challenge and critique manual therapy so much is NOT because I don’t think it can’t help people. It can, for some, for a bit, for a short while. It’s just not that special, skilled or specific that many like to think or claim.
I criticise manual therapy because I just don’t think it deserves the time, energy, effort, respect, or reverence it gets from therapists or patients. Manual therapy is a pretty low-value treatment that doesn’t need years of dedicated study or practice, or thousands of pounds, dollars, yen, or shekels spent on it to perfect. Personally, I think manual therapy sucks because of its arrogant, aloof, egotistical and elitist attitude that many of its gurus, tutors, and associations have.
Sick and Tired
I am sick and tired of soft-skinned megalomanic manual therapists thinking they have some sort of intellectual superiority or moral high ground over other therapists just because they crack a few necks and give out back rubs.
I am sick and tired of hearing many dedicated young physios telling me they feel demoralised and discouraged because they are made to feel foolish and inferior by these self-obsessed narcissistic wassocks who think they can feel sacrums move or a multifidus fire late.
I am sick and tired of the manual therapy fraternities who are more interested in monthly subscriptions than patient benefits, whose members look down and belittle others because they haven’t passed their group’s pseudo-scientific entrance exams and hazing rituals.
I am sick and tired of all the bluff, bluster, and bull shit that constantly oozes from the manual therapy community, such as muscle knots, fascial adhesions, overactive psoas, underactive glutes, wonky thoracic rings, or twisted pelvic joints.
Manual Therapy Sucks
I will say again that Manual Therapy Sucks NOT because it doesn’t or can’t help some in pain or with a disabilit. Manual therapy SUCKS because of all the above. If manual therapy could rid itself of all the over-complicated pseudo-scientific egotistical narcissistic bollocks and pathetic whiney editorials that infests and surrounds it then I think it could be more effective for more than it currently is.
I will however still continue to argue that manual therapy as a treatment does not belong in an evidence-based healthcare profession being administered by highly trained degree qualified clinicians due to the time-cost/reward ratio. Instead, manual therapy should be given as a service by less qualified non-diagnostic therapists at lower costs and greater reward ratio for patients.
ALL these points I make do NOT apply to ALL manual therapists, just a good few of those in so-called positions of authority. I know many excellent manual therapists who use their hands-on techniques simply, rationally, and within a patient-centred well-rounded treatment program. I know many excellent manual therapists who also join me in my rants and share my frustrations against the bullshit and bollocks in their midst. For them, I am forever grateful.
I will end by saying that these pathetic pieces of writing are only more fuel to my fire that proves the manual therapy dinosaurs are becoming more and more threatened that their days of rule, reign, and regulation are coming to an end. And in my opinion the sooner the better. Viva la revolution.
I’ve been trying for many years to get myself and other physios, therapists, trainers and coaches comfortable with simplicity in our assessments and interventions. Unfortunately, I don’t think I’ve been very successful as I constantly find myself confronted with many who over-complicate what they do, how they do it, and why they do it.
Why so many people are attracted to complex and complicated methods over simpler ones is ironically both complex and complicated, but it’s mostly due to something called ‘complexity bias’ which is a trait that we all suffer from that gives undue credence and priority to complex ideas, concepts, and methods over simpler ones.
Complexity bias states that when faced with two competing theories, we are often more likely to choose the more complex one rather than the simpler one. As a result, when we are confronted by a problem, we tend to overlook or ignore simpler solutions and hunt for more complex difficult ones.
You Have A Bias Towards Complexity
Now if you don’t believe me that you just love to make things more complicated for yourself than you need to, just try this little experiment out for me. All I want you to do, using as simple logic as you can, is tell me what you think the next number in this sequence is…
3, 5, 7…
Now I bet most of you immediately thought of 9 as it’s the very clear simple and obvious answer in a list of ascending odd numbers. However, I bet a few of you smarter cookies may have thought of 11 thinking this is the next number in a list of ascending prime numbers. Well, both of these answers to this problem are correct, and they are simple and straight-forward solutions to this problem. But there’s an even simpler answer that I bet all of you overlooked and nicely highlights our bias towards complexity.
The numbers 3, 5, and 7 are indeed ascending odd, and ascending prime numbers, but they are first and foremost simply just ascending numbers. Our natural inherent bias towards complexity and pattern recognition immediately overlooked the simpler answer of ascending numbers and saw the more complex solution of ascending odd or ascending prime numbers instead.
So although you are still correct and solved this problem by saying the numbers 9 or 11 as a solution, you would have not fully understood why you were correct or how you solved the problem. Our complexity bias can therefore not only cause us to make inaccurate or incomplete conclusions to problems but more importantly, it can make it unnecessarily difficult for us to continue solving simple problems.
Our complexity biases often make things much harder for us and others around us than they need to be, they also can give us a false illusion of solving a problem. For example, when we treat people with pain or injury with say some manual therapy, or a bit of tape, or even our exercise our complexity bias tends to assume it’s our treatments that have helped when in fact there could be a much simpler explanation of time and reassurance helping someone underneath or treatments.
We Prefer Complex Over Simple
Now don’t worry if you feel a little foolish now for not recognising 3, 5, and 7 are simply just ascending numbers because back in 1989 a study conducted on 91 mathematic students at Santa Barbara University in California found they all did exactly the same thing when asked to work out the rule on a set of three ascending numbers. Highlighting how complexity bias can affect all of us no matter our intelligence or interlect.
Humans are without doubt very very complex both psychologically but also physically containing many individual parts that combine to form a collective that often can’t be separated from its components. We’re made up of trillions of cells, billions of neurons, thousands of muscles, tendons, ligaments, bones and sinew. Our many systems are interwoven and interdependent on each other and although we have amazing adaptability and resilience there are times when these parts, components and systems can fail leading us to develop pathology, pain, injury and illness.
Yet despite all this complexity for how and why we get pathology, injury and pain, our interventions and treatments can often be very simple and straight-forward. Unfortunately, many clinicians in healthcare do not feel confident or comfortable in thinking this way due to the time and effort they have invested into learning all the complexity of the human body and its diseases and pathologies.
So many clinicians look for complex and complicated reasons and solutions for patients’ pains and problems, without first considering more simpler straight-forward ones first. For example, physios are quick to blame a patient’s shoulder pain on faulty scapula biomechanics rather than recognising they have just played a little too much tennis last week. Or they will associate a patients neck pain on their excessive foot pronation, that’s causing increased knee valgus, hip adduction, and anterior pelvic tilt, which is then adversely affecting their deep oblique spiral fascial sling or some other bollocks, rather than recognising the patient has just recently lost their job, is stressed out to the max, and hasn’t slept well in weeks.
This issue of over-complication occurs not only in our roles as healthcare clinicians but also in all aspects of our lives, with many companies’ actually playing on marketing to our complexity biases all the time. They often do this by incorporating confusing language or insignificant details into their product packaging or advertising to hook us with complexity, such as we are more likely to buy face cream with ‘peptides’ in it, foods with ‘probiotics’, and TV’s with ‘4K HD’, even those these terms mean very little to most of us.
Complex Is Not Chaos
We also have a habit of trying to make sense and solve things that can not be solved seeing complexity and patterns where only chaos exists. This can manifest in many forms, such as seeing conspiracy theories, having superstitions, and falling for logical fallacies.
The distinction between complex and chaos is not just a semantic one as it can have some pretty dire consequences. For example, when we perceive something as complicated when it is in fact chaotic, we are more likely to think it is predictable and therefore controllable.
This can mean we waste a lot of time, energy, effort in trying to control the uncontrollable and ignoring the simpler controllable. This can lead us to make mistakes such as trying to predict who is going to get injured when playing sports and fool ourselves that our movement screens and other tests are controlling the many chaotic factors that contribute to injury and so ignore other controllable factors such as load and recovery management. (ref).
Complexity bias is an interesting dilemma because it seems to go against the other cognitive biases we suffer from that occur to save us mental energy and effort such as confirmation bias which allows us to avoid the effort of updating our beliefs. But complexity bias is, in fact, another mental shortcut allowing us to actually think less by sidestepping the need to understand complex issues.
The Problem With Complexity
The other issue with thinking or intervening with more complexity is that it has more chance of going wrong. The more individual parts a complex system has the greater the chance it has to break down. Complex systems are difficult to maintain because addressing one of its constituent parts inevitably affects another.
This is why complexity is far LESS common in the natural world than you think because it’s unsustainable without a lot of effort, constant maintenance, self-organisation, and/or adaptation. Instead its often chaos that tends to disguise itself as complexity.
Complexity Bias and Language
Another area where we can suffer from over complexity is in our language. We have all had a conversation with or been guilty ourselves of using big fancy words, complex jargon, and 10 words when 1 would have sufficed. We have all heard people say things that we do not understand, but which we do not question for fear of appearing dumb and stupid.
I see so much biomechanical, medical jargon, and downright neuro-babble used by physios, therapists, trainers and coaches often to give them the illusion of knowledge, skill, and intelligence when in fact I think it’s often just a smokescreen to hide their inadequacies and inferiorities. When therapists and trainers use this kind of complexity in their language they create barriers that reduce the chances of others understanding them, which may be non-intentional for some but I think it is often used intentionally by many as a deterrent to others questioning or challenging them.
One of my favourite papers demonstrating this over complexity in language is Gordon Pennycooks’ 2015 study brilliantly titled ‘On the reception and detection of pseudo-profound bullshit’. In this, he uses four trials that demonstrate how people are more inclined to rate random, vague, complex-sounding bollocks as both profound, scientific, and intelligent. He even used one of social media’s biggest neuro-babblers Deepak Chopra’s tweets for this.
Unnecessarily complex language is not only annoying, but it can also be harmful. The use of jargon in areas such as healthcare can and does leave patients confused, alienated, and removed from important decisions. It also leads other clinicians to believe that they are not intelligent enough to challenge what others are saying, meaning poor practice, errors and mistakes are often not questioned or avoided.
Now don’t get me wrong I think some technical terms and jargon does have its place in healthcare, in some specific contexts, and sometimes its absolutely vital. But in everyday communication, its use is an attempt to sound more intelligent and deter any questioning, challenge and/or critique.
So how Can We Overcome Complexity Bias?
The most effective tool we have for overcoming complexity bias is Occam’s razor. Also known as the principle of parsimony, Occam’s razor suggests that the simplest solution or explanation is usually the correct one.
An important point to note is that Occam’s razor does NOT state that the simplest hypothesis IS the correct one, rather that it is the best option based on the available evidence currently until new information is received. Occams Razor can be really useful in situations where empirical data is difficult to collect, such as when deciding what’s the most likely cause of shoulder pain in this tennis player in front of me… is it their faulty scapula movements which I don’t know if they are faulty because I didn’t assess them before they had pain, or from his increased training due to competition coming up that they just told me about?
So that’s my little trip through some reasons why you hate simplicity and prefer complexity.I hope you have found it useful and remember any fool can and often does make anything more complicated. However, it takes a touch of genius and a lot of courage to move in the opposite direction and make things as simple as possible, without making them simpler.
As always thanks for reading, and if you want to try and find some simplicity in shoulder pain then please come and check out my LIVE+ONLINE courses below and here.
So it’s the end of the year and the end of a decade, it’s also the end of me be doing my 100 reps a day challenges that I have been posting on social media for the past 5 months under the hashtag of #Team100. So when things that come to an end its good to look back and reflect a little on what they have taught you.
I know it seems strange to be stopping a physical challenge for the new year when many are thinking about starting one, but after more than 150 continuous days of posting videos of me doing exercises, I think its time to move on. I will, however, be trying to continue the habit of doing a 100 push-ups, or sit-ups, or squats, or even the dreaded burpees a day, I just won’t be filming them anymore.
These challenges have been an interesting experience that has not only got me fitter and stronger but has also given me some useful insights into the challenges, issues, and barriers that everyone faces when trying to increase their physical activity. It has also given me some ideas of how to overcome these issues and barriers myself and for those I see and manage as a physio.
There is no doubt that participating in any daily physical activity is difficult for many reasons. Things such as lack of time, motivation, resources, support and encouragement being the most common, and for patients, there is also pain and disability to consider, all things I have discussed in previous posts here.
I have personally found these challenges not only physically difficult at times causing me pain, soreness, and fatigue, but I have also found them extremely challenging due to there monotony, boredom, and just the time it takes to do and film them, with my work, travel and other training commitments often getting in the way. It’s been these time and boredom factors that I have found far harder to deal with and overcome than the soreness and effort ones, and I’m sure it no different for many of our patients.
So what have I found to be the solution to overcome these time and boredom barriers to daily repetitive, and challenging exercise? Well don’t get too excited as its nothing that clever, or special, or groundbreaking, in fact, it’s something rather plain and simple… its accountability.
Without a doubt, I think the biggest reason for me being so committed, dedicated, and disciplined with these tough and sometimes boring challenges for more than 150 consecutive days is that I made a rather large and public declaration to 1000’s of you on social media that I would do them.
I’ve found that there is nothing like some public accountability to others and a little bit of peer pressure to get you up off your arse and get shit done. I know many think that motivation, discipline, and resilience which I have discussed before here and here should be internal, but do not exclude the external factors that also contribute to someone being a tough, steely-eyed, disciplined, and motivated fucker.
I think it’s far easier to let yourself down than it is to let others down, and the more people you have the opportunity to disappoint and let down, I think the less likely you will.
Don’t get me wrong there are also a host of other positive motivators for declaring and posting these challenges on social media in front of 1000’s of friends and strangers that I have found beneficial as well. The likes, comments, reposts, and seeing others taking part in the challenges themselves were all huge positive motivators for me, especially seeing a 93 year old grandma doing her arm raises…
However, as nice as it was to get encouraging comments, 100’s of likes, and many reposts during these challenges, the bigger motivator for me was my fear of being thought of or being called a letdown, a disappointment, or a loser for not doing them. I know many motivational or behavioural experts will say that positive reinforcement and motivation always outperform, outlast, and outweigh negative motivators, but after doing these challenges I’m not so sure that’s true for everyone.
I now often use what I have learnt about the powerful effects of accountability from these challenges with many of my patients. I now often ask patients to consider not only just telling their close family about their rehab program and schedule, but also to consider posting it on their social media for all of their close and not so close friends and family to see.
Social Media Rehab
I ask patients to make a pledge on social media about their rehab and then film themselves doing it and post it online so as many others can see it. I explain that hopefully, it will give them some motivation to get it done, as well as give others the opportunity to watch and encourage them with it. It will also give them a visual record of their progress so they can see how they are improving over time.
I know this is only an anecdote, so don’t take my word for it at all, but I would guess that I see many of my patient’s adherence to rehab rates go from around 30-40% to 80-90% when they do this.
I also think this is a great way to help not just patients succeed with their rehab but also ANYONE succeed with their goals or resolutions.
New Year Resolutions
The new year is often a time when many make resolutions to get fitter, lose weight, or make some other lifestyle change, and I see many resolution naysayers and sceptics saying they are a waste of time, don’t last, and so don’t bother. This pisses me off no end!
I have discussed the issues with new years resolutions before here and how they often don’t last, with some studies showing 25% don’t last even 1 week and only 8% are actually achieved for many reasons which I won’t go into again.
However New Years resolutions don’t fail just because they are made in the new year, resolutions fail just as often (if not more often) when they are made at any time. Again the reasons and solutions for these I’ve discussed in my other blog which you can go and read if you want here.
Personally I have loved doing these 100 reps a day challenges, and I would like to thank all who have joined in, especially the legends that are Bill Vicenzino and Andrew McCauley who have without doubt been the two most committed and dedicated members of #Team100.
In summary, I think if more physio and healthcare professionals were to engage or experience a monthly physical challenge like #Team100, or even just try and do the rehab protocol or program they ask their patients to do, they will get great insights into the barriers and issues their patients face.
More importantly, if more physios experienced for themselves what they ask their patients to do, I think it would hugely improve their rehab programming and planning. I think many physios will soon recognise the stupidity and irrationality of what they often ask patients to do, and they won’t roll their eyes as much when patients tell them that they haven’t done their exercises.
So once again thanks to everyone who joined in, supported, shared, commented or just eye-rolled at my monthly 100 reps a day challenge. I wish you all a Happy New Year and good luck with any goals or resolutions you have made for 2020 and hope you consider the power of social media accountability.
It’s been a while since I’ve posted anything due to some stuff getting in the way of other stuff, but I’m back and I want to talk about something I’m very interested in, resilience.I strive every day with every patient I see to try to restore, improve, or enhance their resiliency in the face of their pain and/or disability. This may be by encouraging them to continue with activities or tasks that hurt, or getting them to exercise a little more, or just to make some small lifestyle change.
However, after reading this excellent article on resiliency here I’ve had a rather sudden and dramatic realisation that I’ve probably NOT been doing this as well as I thought, and I have probably been approaching it in completely the wrong way.
In this article, Dr Ungar a professor of social science and a family therapist eloquently highlights how an individual can have all the internal resources of resiliency such as knowledge, motivation, and a plan, yet these will be of little use without a supportive environment in which to action them in. He also points out that if the external resources are not available then we are better off trying to change these first before we try to change individuals.
Striving to improve the ability of an individual to continue on in the face of adversity, such as pain, disease or disability will just not work when their families, workplaces, communities, healthcare providers, and governments fail to provide sufficient resources, care, or support.
This realisation hit me like a tonne of bricks! There I’ve been for years trying to get my patients robust and resilient to their pains and disabilities, yet there I’ve been largely ignoring and overlooking their environment that may impede, limit, or even prevent it.
This article has made me recognise that I’ve been getting frustrated with some patients and rather harshly and unfairly blaming them for having a lack of resiliency when this may have been more due to factors outside of their control rather than any fault of their own.
Are you really resilient?
This article has also made me reflect on my own resiliency. I like to think of myself as a pretty resilient person having overcome my fair share of issues in life such as being bullied through most of my school years, suffering unexpected family bereavement, a break down of a very close meaningful relationship, a sudden and unexpected loss of employment forcing a complete career change. I used to think that I overcame these issues through my resilience and robustness, and I suppose I did to an extent, but I can now see that my own resilience is largely due to my environment and social context.
The first thing to consider is that I am a middle-class white heterosexual male, meaning that I am already in a more advantageous position than many others due to long-standing, hard-wired prejudices and biases in our society. I also come from a loving and supportive family who work hard and although not the wealthiest have never had to go without much. It’s these environmental and social factors that I now recognise have mostly made me resilient, or have they?
I do now wonder how I would behave and cope if I didn’t have these experiences and opportunities growing up and found myself in other difficult situations such as living in a different social class, suffering a sudden chronic injury or illness, or being made homeless. I recognise its all well and good me talking about how resilient I think I am whilst sitting on my comfy sofa, with my central heating on, drinking a glass of red wine, whilst blogging on my Macbook!
When it comes to trying to understand resilience in others I think a good place to start is to recognise that for most people resilience is nurtured not inherent. That is it’s far easier to be a tough, robust, irrepressible fucker when your upbringing and environment allows it.
Unfortunately, we are now living in an age of dissolving resiliency due to our increasingly easier upbringings, lifestyles, and environments. Our society is losing sight of what is difficult, tough, and challenging and as a consequence, we are becoming less tenacious, hardy and healthy.
As health care professionals we need to recognise when a patients background and/or their environment is not conducive to them being resilient and try to improve this first before attempting to improve the individual. This may simply mean offering them more time, support, and encouragement, and not getting frustrated or annoyed when they don’t or can’t do their home exercise program, and being more patient and understanding when they take longer to progress.
In hindsight, I now think I have been guilty of not supporting some patients as well as I could have who I thought lacked will power, commitment, and resilience. I often couldn’t understand or tolerate those who didn’t do the simplest of rehab exercises I gave them, or who came up with ‘excuses’ as to why they didn’t do them.
However, I can now see that perhaps their environment and current situation wasn’t suited for them to commit or engage with a simple rehab program or lifestyle change, and perhaps my frustration and lack of support was the worst thing I could have done for them. Looking back now what I should have done is tried to create a more stable and encouraging environment for them to become more resilient in by asking them to come and do their home exercise program with me supporting and motivating them along the way.
I know this sounds contradictory but for some people to become resilient they need others to help them become resilient. This is where physios and other healthcare providers need to take a close look at each individuals situation and background and decide if they need to step up and do more to help develop resiliency.
Don’t get me wrong, I’m not saying we need to suddenly start getting all those who have missed a weeks home exercise plan in 3 x week for 6-12 months giving them life coaching and cognitive behavioural therapy along the way. But I do think we need to with those whose environments and current situations are not the best for them to engage in regular rehab or lifestyle changes offer them more than we currently do.
The huge problem here is, of course, the lack of resources and staff to do this. Currently, the UK’s National Healthcare Service just doesn’t have the capacity or ability to offer many patients in persistent pain or with a long term disability extended regular care and rehab to any great extent. And I don’t I think private practice should do this, as there is a real risk of financial gain and profits overriding patient care and treatment.
Resilience takes resilience
Another thing to consider is that it takes a lot of resilience to develop someone else’s resilience. To ask physiotherapists or any other healthcare professional to become better at developing patients resiliency they will also need a supportive nurturing encouraging environment, and this is also currently lacking everywhere across the board.
Most physios are simply not given the time, resources or support to develop resilience in the patients they see. Many physios in both the public and private sectors are asked to see as many patients as they can with the primary focus on productivity and profits and patient outcomes and results coming second.
I know this first hand from 15+ years of experience working in both the public and private sector, being asked to see 15-20 patients a day, 5-6 days a week, with any gaps in my diary or dip in my ‘utilisation’ being questioned by my managers as ‘not working hard enough’. I can tell you this is a really shitty working environment and has done shit balls for my empathy and compassion which, unfortunately, meant my patients were the ones who suffered.
Until healthcare employers, managers, commissioners and of course the governmental big wigs recognise that they need to look after those who are looking after patients better, giving them more time, support and resources nothing is going to change quickly.
But to end on a more positive note I would ask all healthcare professionals reading this to go and read the article on resiliency in full, and the next time a patient says they haven’t taken your advice, or done their home exercise programme, take a breath, pause for a second, and before you write them off for having no resilience ask yourself, would you if you were in their shoes!
Whether you like to admit it or not uncertainty exists in everything including ALL aspects of healthcare. There is uncertainty in our assessments, diagnoses, prognoses, and of course our treatments. Being uncertain in healthcare occurs a lot, yet conversely, not many are willing to admit it or talk about it.
And that’s perfectly natural as when we are faced with any uncertainty it makes us feel deeply uncomfortable, awkward, and foolish. Instinctively we avoid, ignore, or deny situations of uncertainty, and this is becoming the norm in our over-confident, unabashed, ego-driven society!
Being uncertain goes against our human nature that we have evolved to be sure in our thinking and decisions which is essential for our survival. Humans, therefore, tend to trust and gravitate towards those who are certain, all knowing, and have answers, over those who don’t. A perfect example of this is on social media.
You only have to look at healthcare professionals with 1000’s of followers to see that their popularity is formed and based most of the time on certainty. They will often display conviction that they have the truth, answers, and knowledge to help those in need.
Rarely will you see a popular social media healthcare ‘celebrity’ express doubt or uncertainty. This needs to change! We all need to acknowledge, admit, and accept uncertainty better, but this ain’t easy, in fact, it’s really bloody difficult!
I don’t know things!
I hate not knowing things, it’s one of the reasons why I read so much in an attempt to learn more and understand things better. But the cruel, cold, heartless paradox of knowledge is the more you learn the more you realise how little you actually know, Dunning and Kruger have a lot to answer for!
I also hate being in a position of having to admit not knowing what to do, or how best to proceed, or more commonly what to say to a patient when they ask me whats the cause of their pain. But this happens a lot in my work. A helluva lot!!!
If you are a well-read evidenced-based healthcare professional, you will realise that our ability to diagnose the cause of someone’s pain is notoriously difficult and uncertain due to many of our tests and procedures being riddled with low specificity, poor reliability, and even worse validity.
This doesn’t mean we give up or become lazy and don’t bother trying to diagnose a patients pain. It just means we realise and recognise that AFTER we have done a full and thorough assessment to the best of our ability, we are often able to rule out anything serious or sinister, but are often left unsure why someone has pain or what is causing it.
Being uncertain in front of patients used to make me feel awkward, foolish and stupid, and it still does at times. This used to make me feel annoyed, frustrated, even angry and it still does at times. However, slowly, steadily, gradually I have learnt to tolerate the uncertainty in myknowledge and my work, and I now think I am getting better at expressing it and passing it onto my patients. But it still isn’t easy!
One of my favourite researchers in uncertainty who has helped me deal with it better is Dr Arabella Simpkin. You may have read her excellent editorial in the New England Journal of Medicine back in 2016 here. If not please go read it now, it is a wonderful piece of writing that summarises and reflects all the issues I am trying to make.
Tips for uncertainty
Dr Simkin has also co-authored this paper here recently published that attempts to give all healthcare professionals ‘tips for thriving in the face of clinical uncertainty’. Again this is a really insightful, useful, and topical paper and I would urge you all to read it in full. I have summarised the key tips they suggest for thriving with uncertainty in healthcare below.
No 1: Be prepared
Try to identify as many areas of uncertainty that you have. Things such as particular pathologies, patients, or procedures that you feel unsure or unclear about. Then to the best of your ability try to reduce this by reading, practising, asking colleagues for assistance. Next prepare yourself for how you will act and react when confronted with not knowing something in front of a patient. Think about what you will say, and how you will say it, and plan what you will do and who can assist you.
No 2: Recognise the type of uncertainty
Is the uncertainty a knowable unknown, or a truly unknown unknown? Diagnosing the type of uncertainty can help you clarify and plan a path forward to suggest appropriate management strategies. The three classifications of uncertainty are…
Sources; such as issues with probability, ambiguity, and complexity
Issues; such as lack of knowledge, practical experience, or personal skills
Locus: who is the uncertainty with, the clinician or the patient
No 3: Be aware of biases
The desire for certainty leaves all of us open to cognitive biases, the main ones to be aware of are…
Availability Bias; Making a diagnosis based on information easily remembered and recalled rather than what’s more likely and probable.
Anchoring Bias: Settling on a diagnosis early on in the assessment and not amending it when new information becomes available.
Representativeness: Comparing a case to previous typical cases via pattern recognition but ignoring other atypical features present.
No 4: Have a plan
Ensure you have a ‘safety net’ for all cases of uncertainty, don’t just ignore them or wash your hands of them. Building a mechanism of follow up into your practice gives clinicians a chance to correct their treatment plan as time and the ‘illness’ evolves if a wrong decision was made in the early stages when limited information was available.
No 5: Have a network
Surround yourself with colleagues and peers who you feel comfortable and safe in expressing uncertainty and doubt with. Use them as a soundboard to share ideas and gage opinion on what to do and how to proceed.
However, try not to only limit this group to ‘your tribe’ or speciality. Use and employ colleagues from other areas and disciplines of healthcare for a wider more varied view.
No 6: Be a role model
Talking openly about uncertainty helps normalise it and can help set a culture that embraces uncertainty. Never be afraid to say ‘I don’t know’. It can help others around you gain the confidence to do the same and help others realise that sharing uncertainty is what good healthcare culture should be.
No 7: Promote curiosity
Curiosity is a basic element of understanding and a key motivator for learning. Appreciate and reward others for expressing curiosity and make time to discuss and answer questions. Use ‘how’ and ‘why’ questions rather than ‘what’ and ‘when’, and consider using the more flexible word ‘hypothesis’ more than the fixed and rigid ‘diagnosis’
No 8: Discuss uncertainty openly with patients
This, in my opinion, is the most important, and the most the challenging aspect of uncertainty in healthcare. However, the question is not whether we should share uncertainty with our patients but how best to do it without losing their confidence or causing them anxiety.
Although we all worry about the negative effects of admitting uncertainty to patients there is research that suggests expressions of uncertainty can lead to stronger patient-clinician relationships (ref). When clinicians are open and honest in response to patients questions using phrases such as ‘i don’t know‘ or ‘its not clear’ there is often higher patient engagement and satisfaction (ref).
In my experience, no patient likes to be fobbed off or bull shitted too and often they know when this is being done. So when asked a question that you can not, or do not know how to answer, do not fear saying ‘I don’t know’. Expressing uncertainty to your patients doesn’t make you appear ignorant, inexperienced, or foolish. If anything being too confident and certain can make you appear arrogant, aloof, and an arsehole.
I have found that once you get over your own inadequacy issues and inferiority complexes and start to say ‘I don’t know’ more often, it does get easier. I have also found the key to success in expressing uncertainty with patients is to do it compassionately, empathetically, but most important of all, do it confidently.
I am often uncertain as to exactly what, where, or why someone has pain, but I am often confident that there is nothing serious or sinister and that they can get a good outcome with time, rehab, lifestyle modifications and that I will do my best to help, support, and encourage them to achieve this.
So in summary, as a healthcare professional learn to be confidently uncertain in an ever-increasingly certain world!
When involved a debate or an argument it’s very easy for the main points to get lost or twisted amongst the claims, counterclaims, or the general shit flinging that tends to occur. This happens a lot in many discussions, but it occurs the most whenever I’m involved in a debate about manual therapy and its role within the physiotherapy profession.
It’s no secret that I have had my fair share of disagreements over the years with many of the leaders, gurus, and celebrities of all the manual therapy treatments such as joint manipulations, mobilisations with movements, soft tissue massage, and myofascial release. I have made public and voiced my frustrations, dislikes, and even hatred of all these interventions many times on social media and in my blogs for years, and I will continue to do so.
It’s also fair to say that I have some strong polarising opinions about ALL manual therapy, but believe it or not, I welcome the disagreements they create. Despite many of the physiotherapy top brass and elite claiming that these arguments are harmful and detrimental for the profession, I think the opposite.
As George Patton famously said, “if everyone is agreeing, then someone isn’t thinking”. In my opinion, open, honest, passionate, heated disagreement is a sign of a profession and the individuals within it trying to sort out what’s good from bad, better from worse, less wrong and more likely right. It’s disagreements that often drive change and progress.
However, as much as I welcome the disagreements and debates around my views on manual therapy what annoys and frustrates me the most is when people twist, contort or misrepresent them. This usually occurs due to others ignorance, stupidity, or simply because they dislike me.
So when I read a spectacular misrepresentation of my arguments around manual therapy by someone I consider neither ignorant or stupid and who I like and respect, I was a little surprised and taken aback. These were my feelings when I read Roger Kerry’s recent piece titled ‘Hands on, hands off: is that even a thing?
In this article, Roger references a few of my blogs and appears to have highlighted me as the reprehensible social media pariah of physiotherapy! Underneath his extensive vocabulary, fancy words, and charming rhetoric, Roger attempts to paint me and others who question and challenge manual therapy on social media as ‘non-differentiating, tired, and vacuous’ and more annoyingly that we advocate a ‘hands-off’ approach.
This is a breathtakingly inaccurate and frustrating straw man argument that I hear often from manual therapy supporters in an attempt to undermine and distract attention away from my real arguments against manual therapy as a healthcare treatment.
I find it ironic that at the start of this article Roger states the hands-on, hands-off debate is a false dichotomy when actually none of my arguments against manual therapy are about hands on or hands off. Rogers choice of words in using ‘hands-on, hands-off’ rather than ‘manual therapy, or no manual therapy’ is a deliberate ploy to misrepresent my position and in doing so he has essentially created his own false dichotomy, which is kind of strange for a professor of philosophy.
My arguments for reducing, removing, and even abandoning manual therapy by the physiotherapy profession is not, nor ever has been about suggesting that physiotherapists stop touching their patients. This is an absurd but clever distraction away from my true positions against manual therapy as a healthcare intervention.
So I will reiterate once again why I think manual therapy ‘sucks’ and why I think it should be abandoned by most physiotherapists. My first reason is due to the constant and continued misinformation about what manual therapy does, and how it does it. Despite it being 2019 and a large evidence base many physios still stubbornly and dogmatically teach and explain that manual therapy corrects and adjusts faulty joint positions or mobility issues, that it lengthens and releases muscles, fascia and other soft tissues when it simply can not, and does not (ref).
Another reason I think manual therapy should be ‘abandoned’ is due to it being over-complicated, over-hyped, over-used, and over-priced for what it achieves (ref). Most manual therapy at best gives some people, some small, short-lasting transient effects on their pain which may or may not affect their function (ref). If manual therapy were a drug it would never be prescribed as its effects are so low and cost so high when compared to other simpler cheaper alternatives (ref).
My other argument for ‘leaving’ manual therapy behind is that its a huge distraction for therapists and patients, stealing their time and attention away from active rehabilitation interventions that have bigger and better health benefits (ref). In the UK most MSK physios have very limited time with patients, anywhere from 2 to 8 sessions that last between 20-45 minutes on average (ref). In this time they have to gain a history, do a physical exam, consider any imaging and investigations, develop a working diagnosis, formulate a treatment plan, give advice and education, and practice and rehearse rehabilitation strategies.
If all of the above is being done thoroughly and to the best ability there simply can not be enough time for the application of manual therapy. When manual therapy is used what often tends to get compromised is the active rehabilitation. I know many physios disagree with me here and they say they can do both manual therapy and active rehabilitation well, but I call bullshit on that.
When I used to use manual therapy in my practice it always reduced the time I had with patients to explore, experiment, and rehearse movements and exercises, and tinker with loading parameters. I know this is anecdotal so can’t be trusted but I hear many patients telling me about physiotherapy sessions in which they had manual therapy and how either no rehab was given at all, or if it was, it was at the end of the session given as an after-thought, usually, by the physio handing them a sheet of photocopied exercises to do at home with no explanation or practice to ensure they could do them, or that they were even beneficial for them.
Finally and by no means least, I simply hate ALL manual therapy for the pompous arrogant elitism and showmanship that surrounds ALL of it and most of those that use and teach it. No matter how well presented and explained manual therapy instils a belief of skill, specialism, and superiority that it simply doesn’t deserve.
Manual therapy also instils a notion and belief that physios ‘fix’ patients rather than help them. Manual therapy takes our profession away from our rehabilitation and exercise foundations and closer to the loons and quacks in the complementary and alternative medicine fields with their crystals and chakras.
I personally believe that most physios use manual therapy more for their own benefit than that of their patients. Manual therapy is often there to pander and pamper patients rather than genuinely help them. Manual therapy makes the therapist feel special and needed, and hides their inability to prescribe good quality robust rehab or address the harder, tougher more difficult factors around a patients pain and disability.
I know many think I am unprofessional and harmful to our profession for saying this! I don’t care, because I actually think physios fannying around with manual therapy distracting patients from things they need to do and adversely affecting their outcomes is far more unprofessional and far more harmful to our profession.
NO manual therapy doesn’t mean NO touching
However, as much as I dislike/hate/loathe manual therapy for all the reasons above, I will state again that I have never suggested or implied that physiotherapists should stop touching their patients and go ‘hands-off’. In fact I recently wrote a blog saying just the opposite here.
Touch and palpation is a basic, fundamental, and vitally important part of any good thorough evidenced-based physical assessment. Although its use diagnostically is poor I cannot emphasise enough the importance of all physiotherapists taking the time care and attention to palpate their patients.
Not only does palpation stop you missing important and vital signs of pathology such as swelling, heat and deformity, it also gives patients the reassurance that you as a healthcare professional have taken their issues and concerns seriously and have examined them thoroughly. One of my ‘many’ pet peeves is listening to patients tell me that some bone idle, lazy, and incompetent healthcare professional didn’t even observe or palpate an area of concern of theirs.
However, as frustrating as it is listening to that, listening to patients who tell me that some other therapist has palpated them and found a bone out of place, or something misaligned, or a muscle knot, or fascial adhesion is far more frustrating, far more common, and a damn sight harder to deal with. The biggest reason these ridiculous, fear-inducing explanations are given to patients is due to therapists being taught and lead to believe that they can feel and diagnose things with palpation that the evidence and simple common sense tells us they cannot (ref).
Physiotherapists often develop these beliefs during their manual therapy training and why I think most of it is best avoided as it continues to be surrounded by so much outdated, non-evidenced nonsense. Roger talks in his article about the reputation of our profession being at risk if we were to go ‘hands-off’ and I agree. But I also think the reputation of our profession is in danger of being adversely affected by the woo and pseudo-science that manual therapy is riddled with.
Until manual therapy is taught in a more simple, rationale, and evidenced-based way I think most healthcare professionals are better off without it. More therapists and patients need to recognise that there is no magic, skill, or specificity in any manual therapy that costs thousands of pounds, euros, or dollars to learn, or that takes years of dedicated practice to master and perfect.
This leads to another of my arguments for physiotherapists to abandon manual therapy, that is they are not the best professionals to be providing it. Physiotherapists are autonomous diagnostic healthcare professionals who studied for 3-5 years to assess, diagnose, and manage those in pain and with disability. They are not best utilised cracking necks, giving back rubs, or applying hot packs.
For any manual therapy to be effective I believe it needs to be given by therapists who are solely focused on it, who work in calm relaxing environments, who can take the time and attention to work on the patient’s body slowly, methodically, and holistically. This is just not how physiotherapists use manual therapy, instead it’s usually rushed and done in a few minutes or less, in environments that are far from relaxing, and often they are focused on other things around the patient’s care.
Physios training, skills and time are simply better used for other things. This is not meant to sound arrogant, condescending, or conceited just honest, rationale, and pragmatic. I see a physio giving a patient a massage the same way as I see a cardio-thoracic surgeon emptying a patients bed pan. Its not that they couldn’t or shouldn’t do it, its that they are better trained and skilled for other things!
Although it frustrates the hell out of me that the manual therapy debate is often contorted and bastardised into a hands-on, hands-off false dichotomy, I am happy that the debate is still here be had. Despite what Roger tries to present in his article, the well-rehearsed manual therapy debate is far from tired or vacuous, it is an important discussion to be had, and it’s not just a construct of today’s modern social media.
The debate about the pros and cons of manual therapy within physiotherapy has been raging for decades long before I got involved, and long before social media was around. The likes of the late great Robin McKenzie, Louis Gifford, Max Zusman, Jules Rothstein were all known for questioning and challenging the over-use, over-complication, and utter bollocks that surrounds manual therapy long before Insta-Google-Face-Tweetbook was ever invented.
Social media isn’t to blame for these debates and disagreements as they have been always been around. All social media has done is make these discussions, debates and arguments more known and accessible which is a good thing. Again, some will argue that this is harmful to our profession and we should be focusing on other more important things, I disagree.
If you’ve made it this far, very well done!!!
Physiotherapy as a science-based profession needs to accept that disagreements are essential for progress. Science and philosophy thrive on discourse. Discourse drives interest, intrigue and investigation. What is far more dangerous and harmful to our profession is dogma, apathy, and lethargy from stagnation and suppression of thoughts and ideas and beliefs, and that what we’ve always done is what we should always do.
Physiotherapy needs to evolve, advance and grow, and to do this it needs to shake off some debris and detritus from the good old days and this means moving on and away from massages and manipulations, but not from palpation and touch.
There is a common saying that three of the most dangerous words used in healthcare are ‘in my experience’ as relying on it can cause some big problems. However, I think there are another three words being used a lot recently that can be just as dangerous, these are ‘research has shown’!
Healthcare has moved away from individuals experience-based practice to a more scientific evidence-based practice in an effort to reduce clinicians bias and ignorance adversely affecting patients care and treatment. This includes physiotherapy where historically clinical experience has often been highly respected and revered over and above science, research and evidence.
Clinical experience is no doubt useful for many things, in fact, I think for some things it is probably the most reliable thing we have (ref). However, clinical experience should never be fully trusted or solely relied upon. History is littered with examples of where experts have relied on their experience too much and been very very wrong at huge costs to others (ref).
Evidence-based practice within physiotherapy is slowly being adopted with more physios reading, engaging, and participating with research which is a great thing. And as much as I’m an advocate for research and evidence, it needs to be recognised that evidence-based practice has some pitfalls if not used and implemented carefully and sensibly.
Unfortunately, I see many physios using research and evidence not carefully or sensibly. In fact, I see some physios using research like a drunk uses a lampost, more for support than illumination. That is they only find research to support what they already think and use it to justify what they already do.
Some therapists think they are evidence-based clinicians if they find a research paper demonstrating that a treatment they use ‘works’ (usually by the p-value being <0.5). But this is NOT how evidence-based practice works!
Evidence-based practice is the very difficult and complex skill of interpreting, synthesizing, weighing, and implementing the whole of the evidence base in its entirety to support our methods, treatments and interventions. It’s not the reading of one, two, or even a few papers that already support your own beliefs. If you’re basing your practice on one or two research papers it’s usually because you have only read one or two research papers and are ignorant of others that may challenge or question them.
Many healthcare professionals, and I will include myself here at times, cherry-pick the evidence-base, using what they want, and ignoring what they don’t want. Most use Pubmed like they use Google doing a quick keyword search, often not going past the first page of results, and clicking on the first paper that catches their eye. This means they often find what they want to know, rather than what they need to know. It also means they get very skewed views and beliefs about what they think works, and what they think doesn’t.
One of the issues with the evidence-base is that there are literally 100’s of papers published to support anything you want, especially in the field of physiotherapy which is notorious for publishing bad science, with lots of low-quality, highly biased, poorly designed research trials (ref). For example, you can find papers showing howwoolly pantscure low back pain, ultrasound appliedclockwiseis more effective, and even spinal manipulationreverses death. There is literally citable research out there to supportwhat you want, or don’t want, such as K-tapehelps, or itdoesn’t, manual therapyhelps, or itdoesn’t, even exercisehelps, or itdoesn’t.
There is literally a shit tonne of shit research out there, and this quagmire of crap is being defecated daily, and means you have to wade waist-deep through the crap to find the good stuff. This is time-consuming, difficult, frustrating, and hard work, and means good quality research is very hard to find and often goes unnoticed, whereas bad research is very easy to find and often gets promoted.
Many say that science and evidence-based practice is broken because of these issues, but that’s nonsense. Evidence-based practice isn’t broken, it’s just very, very, very hard to do well, and often it’s abused and misused by those who don’t understand it. Evidence is a tool, and like any tool, it’s only as good as the person using it.
Unfortunately, levels of scientific literacy and understanding are terrible within the general public and not that much better in healthcare, with most clinicians not able to tell the difference between good quality, rigorous, ethical research from poor quality, flawed, biased research.
It still amazes me how many healthcare professionals hold a Bachelor of Science yet couldn’t tell you the difference between specificity or sensitivity, reliability or validity, efficacy or effectiveness, statistically significant or clinically meaningful. And don’t even get me started on how many clinicians do not understand the issues with p-values, the role of effect sizes, blinding, control groups, randomisation, power, publication bias, data mining, p-hacking, HARKing and the reproduction crisis.
Some really useful resources for better understanding of all the issues I’ve just mentioned can be foundhereandhere, and also check out theScience Dailywebsite and theEverything Hertzpodcast as well, as I often find these excellent resources for improving your understanding of research, statistics and the basic scientific method.
A common misunderstanding of evidence-based practice is that many think it will give them clear and definitive answers. Sometimes it can, but often it doesn’t. Research never really proves anything true. Research often just tells us what’s more probable and less wrong!
Many think research and evidence will give them quick, simple, easy answers to messy, complex and confusing questions about how they should assess, diagnose and manage people with pain. It won’t, not at all. If anything reading research can make things even harder and more complicated, which is why many give up after trying for a bit.
Reading research doesn’t give clinicians answers, it gives them an appreciation of uncertainty and an ability to recognise the probability of what’s less wrong and what’s more right. But only if they’re able to think critically, have good levels of scientific literacy, and more importantly be tolerant of complexity and uncertainty.
Many healthcare professionals lack tolerance to uncertainty as they don’t want to look ignorant or stupid to others. For example, no patient wants to hear or see a clinician dithering and dallying, stuttering and stammering scratching their head wondering what to do next.
A lack of tolerance to uncertainty in healthcare is also due to societal pressures and deeply rooted constructs that healthcare professionals should always know what to do when patients come to see them. It is still assumed by many that the clinician alone decides what to do and how to proceed rather than it being a shared process between the patient and the clinician.
Due to these issues, many clinicians hide and mask their uncertainty by abusing and misusing the research to give them an air of confidence and certainty. This also avoids them having to have difficult and awkward discussions with patients about the uncertainty and complexity of treatments and outcomes.
As I said at the beginning there is no doubt that clinical experience can be useful in some situations, but using it alone is fraught with problems. But, there is also no doubt that relying on poorly conducted, highly biased, and methodologically flawed research has just as many problems.
Healthcare professionals need to be careful that phrases like “I know this works” or “This is what I have always done” are not mindlessly replaced with “the evidence says” or “research has shown”.
Musculoskeletal physiotherapy I think is going through an identity crisis. I don’t mean the kind that makes it dye its hair, wear leather trousers, or tries to impress other professions half its age. Rather I think musculoskeletal physiotherapy is struggling to find its place and purpose in healthcare system and so is trying to do new things and is loosing sight of what its real role should be.
The physiotherapy profession has produced a huge amount of research in the last 20 years in an attempt to demonstrate its worth and effectiveness. However, a lot of it highlights that physiotherapy has little to no significant effect above placebos, natural history, or regression to the mean, and people are beginning to notice (ref).
This has created a lot of debate within physio with many advocates fighting hard for their cherished treatments, and others like myself questioning their worth. Some have talked about this crisis with blogs telling us how‘physio will eat itself’and books called‘The End of Physiotherapy’both of which I urge you to read.
However, physiotherapy continues to desperately search for evidence to prove it worth and earn its place within healthcare, with debates and arguments raging on about what are the best treatments for this pathology or that problem. But has physiotherapy and many within it (including myself) focused its efforts and energy in the wrong place? Has physiotherapy lost sight of what it could be preventing rather than what it can treat, and is it in need of a drastic shift in its identity of what it does and how it does it as a profession?
Treat or Prevent?
The vast majority of physiotherapy research and physios themselves invest a lot of their time, energy and effort into diagnosing and treating pathology, disease, and disability. This is clearly important and should be continued, but what about the other side of the coin? What about our efforts in the prevention of pathology, disease, and disability?
Does the physiotherapy profession invest as much time, energy, and effort trying to prevent disease, and disability as it does trying to treat it? Does the physiotherapy profession place as much importance and relevance on the promotion of health and wellness as it does on the treatment of sickness and illness?
Simply put… HELL NO!!!
Most, if not all of physiotherapy’s training, research, practice, and effort is focused on the reduction of pain and the improvement of function in those WITH disease or pathology. Very little, if any time, attention, or resources are given to ideas, methods or strategies to prevent or reduce the prevalence of disease and pathology.
Simply put… Physiotherapy is a reactive profession, not a proactive one!
And this applies not just to physiotherapy but to all of healthcare, with the National Health Service in the UK better described as the National Sick Service as it does very little to help educate, influence or change the nations behaviour to help improve its health.
Now I am not just trying to be hyper-critical or overly negative here, and I know there are some within the NHS and some physios who do work proactively in some health promotion roles, but they are in the minority, and they are not well supported, funded, seen or heard. This, in my opinion, needs to change drastically.
Currently, physiotherapy along with many other healthcare sickcare professions are bogged down in the endless ever-increasing pressures of treating pain, pathology, disease, and disability to do much about the prevention or reduction of them. This is a classic vicious cycle if there ever was one, and it’s one that is leading us into a right royal shitstorm.
Tsunami of Disease
With an ever-increasing ageing population that is doing less and less physical activity, with poorer and poorer lifestyle behaviours, declining health, and greater co-morbidities, are inevitable and our healthcare system is facing a tsunami of chronic illnesses and disabilities that it can never hope to manage and is going to be swamped very soon.
It is estimated that by 2050 the UK’s population will have expanded by another 10 million people with a significant increase in those over the age of 60 (ref). This increasing elderly population will have far higher rates of chronic long lasting morbidities such as obesity, diabetes, and cardiovascular disease, that will require long term treatments and support.
It is estimated that in just 10 years over half of the UKs population will be clinically obese and the associated health issues of this alone will cost the NHS a staggering £25 billion (ref). Thats more than all the budgets for research into cardiovascular disease, cancer, and diabetes combined (ref).
There is no way our healthcare or financial systems can cope with this, and if they only keep focusing on treating rather than preventing disease it will soon find itself overrun by the chronically ill and disabled needing constant care. Therefore, more time, effort, resources and opportunities need to be placed as a priority into the prevention of disease and illness, and I think the physiotherapy profession is in a prime position to help here.
However, as I said the physiotherapy profession is very much focused on only the diagnosis and treatment of disease and illness rather than the promotion of health and wellness. And if you don’t believe me just take a look at its recent training, career structure, and its position within health care and society in general, especially now with it emphasis on first contact, extended scope, and advanced practitioners who essentially are cheaper, poorly trained, and less skilled GPs and specialist registrars!
Currently, in most physiotherapy training very little time is spent on health and wellness promotion and advocacy. This needs to change! More emphasis, time, and energy are needed to train and enthuse current and future physios on the importance of health promotion and advocacy in all those they see.
physios need more support, encouragement, training and skills in how to communicate, motivate and encourage behavioural change in all those they see with some minor aches and pains or injury, knowing how to overcome barriers and obstacles to healthy lifestyles, far more than they need to know what settings to use on an ultrasound machine, where to place an acupuncture needle, or how to go a grade 3 mobilisation on L4/5.
Most if not all musculoskeletal physiotherapy career pathways are focused on and dedicated towards extended or advanced skills in diagnosis and treatment, there are virtually no career options for those physios who want to focus on health and wellness promotion. This needs to change!
For an MSK physiotherapist to progress their career they have to do further training in either manual therapy, acupuncture, dry needling, diagnostic imaging, injections, blood tests, even prescribing medications. For an MSK physio to be seen as advanced, enhanced, or specialised they have to twist, contort, and turn themselves into some bastardised version of a doctor, registrar, or radiologist. I know this because I have done it myself, and I don’t like it.
And this is not to be disparaging, negative or critical of all the ESPs, APPs, or FCPs or whatever you want to call them, as again I am one, and I know there are some excellent ones doing some excellent work. But where are the Extended Scope Physios in health promotion?
Where are the Advanced Physio Practitioners in exercise and activity prescription? Where are the First Contact Physios in schools educating children on the importance of healthy lifestyles?
The MSK physiotherapy profession needs to take a long hard look at its training and career structure, and stop placing as much emphasis and credence on skills that only diagnose or treat those with pain and pathology. It needs to start to place more emphasis, training, focus on skills and attributes that promote health and wellness. Simply put we need more physios enthusiastic and striving to become health and wellness advocates, not junior doctors.
Physio in society
Currently, most if not all MSK physiotherapy is positioned in reactive roles, treating people with problems sent to them. It is also still very much seen as a junior, inferior, even subservient profession to other medical professions. This needs to change!
More MSK physiotherapy needs to position itself outside of hospitals and medical centres, and into gyms, health centres, and even schools. Health promotion and advocacy should begin from a young age and physiotherapy should be lobbying governments and pressuring policymakers about the benefits of placing physiotherapists and health and wellness teachers into the national curriculum.
MSK physiotherapy wants to try and position itself as being seen as a profession that helps promote health and wellness as much as it helps treat disease and illness. Our leaders and societies need to do more to push this forward using lobbying and other political pressure.
With the World Congress of Physiotherapy currently on in Geneva this weekend, it is encouraging to see the odd slide and comment about this already, but more needs to be done and I do wonder how much of this is talk and how much action will come of it?
As I mentioned at the beginning, the MSK physiotherapy profession needs a drastic shift in its identity and thinking of what it is, what it does, and where its role and worth lies. Is it in the diagnosing and treatment of pain and pathology, which hasn’t been shown to be that great or effective, or is it more in the prevention and reduction of pain and pathology through the promotion and advocacy of health and wellness?
Obviously, the answer is both! But at the moment MSK physiotherapy is very much focused on the treating more than the preventing, it’s more reactive than proactive, and if it wants to survive and be taken seriously as a ‘health care’ profession this needs to change!
I’ve been blown away by the response and feedback from my recent blog onabandoning manual therapy. In less than 24 hours I have had numerous emails and messages from many of you experiencing the same problems and pressures to use manual therapy by your colleagues, managers, and patients, not because it helps that much, but rather because it’s expected.
It’s great to hear that many of you now don’t feel as isolated or alone knowing that others are in the same position. It’s also great to hear that many of you are now prepared to challenge this culture around manual therapy, which is exactly what I hoped the blog would achieve.
However, there has been some criticism, some constructive, some not so much. This is good, it keeps me on my toes and thinking hard, and I always think it means I’m doing something right if I piss certain people off. There have also been a few fallacies thrown around such as I only critique manual therapy as I’m no good at it and that I need more experience and training in it.
Well, there is no denying that experience and training can help you become a better therapist, but experience or training of manual therapy does not make you a better therapist. For example, some research has found that therapists experience, specialist training, and certifications do not improve patients outcomes with low back painhere. And, a systematic reviewherehas shown that more experience may actually be a risk of lower quality of care, possibly due to overconfidence as discussedhere.
However, the main point I want to talk about today is the most common justification I have heard from therapists for using manual therapy, in that is it helps patients buy into more active treatments such as exercise. I must hear this justification daily, and I will admit it was one I used to use and believe myself. I don’t anymore.
The common belief that many therapists have is if a patient with back pain, shoulder pain, knee pain, or any other pain has a bit of manual therapy first it will help them do their exercises better and more often. This is unfortunately complete and utter bull shit.
There is zero evidence, nil, nada, zilch, fuck all… that patients who get manual therapy will do their exercises any better or more often than those who don’t get manual therapy. In fact, there is evidenceherethat shows even using strong pain-relieving steroid injections in arthritic knees and subacromial shoulder painherebefore exercise doesn’t significantly improve the effects of exercise, so why would we think a bit of massage will?
There is no doubt or argument from me that exercise adherence of our patients when in pain is poor. In fact, it’s terrible, as low as 20% as found in some researchhere. But don’t be fooled or mislead into thinking that a bit of rubbing or poking will solve, correct or even significantly change this.
What will change patients adherence with exercise when in pain is talking about their concerns and worries, identifying any possible obstacles and barriers, and coming up with simple practical solutions to overcome them as discussedhere. What won’t significantly improve exercise adherence when in pain is a bit of massage or manipulation.
Over the years dealing with many types of people in pain I have come to the conclusion that the simplest and easiest way to get patients to adhere to their exercises when in pain, is to physically supervise, encourage, motivate, and reassure them as they are doing them. I find, and most research supports this, that around 6-12 sessions of exercise therapy (possibly up to 24 sessions for some) done under supervision over 3-6 months for most MSK conditions will ALWAYS outperform 6-12 sessions of any other type of therapy.
I truly believe that if more physios used their time and sessions with patients to actually do the exercises with them, sometimes multiple times a week, rather than faffing around with manual therapy and other passive modalities we would see far better results and outcomes. Patients then wouldn’t then be tempted to seek other more invasive, expensive and risky treatments, and lets not forget that they would also get the many other positive health benefits of exercise as a pleasant side effect.
Yes ok ideally in a perfect world we would like all our patients to be motivated and dedicated to doing their exercises without us having to babysit them. But news flash people we don’t live in a perfect world, we live in a world ofreducing toleranceand low motivation, not to mention poor lifestyle choices and terrible health habits.
In my opinion, physios who spend their time with patients only talking, massaging, manipulating, poking or sticking them, leaving the exercise for the last 5 minutes of the session, handing them a poorly photocopied sheet of shitty exercises to be done at home are the bane of my life and a cancer in our profession.
This lazy, bone idle, disinterested, apathetic attitude towards exercise belittles and devalues the importance and benefit of exercise therapy for many MSK conditions. If a therapist is disinterested, bored, apathetic about exercise, you can guarantee patients will be as well. Is it any surprise that so many patients ‘fail physio’ with this lacklustre approach to exercise and rehab?
Also, don’t think that by giving some patients a bit of manual therapy you will help move them away from wanting it, which is another common justification I hear for its use. I know there are patients who do only want a few sessions of rubbing and poking and then they will be fine, but there are also plenty of patients who ONLY want the rubbing and poking continuously.
I see a good few patients who are fixated on getting hands-on treatments and addicted to the crack, the joint crack that is. These patients only want a joint popping or a muscle rubbed and have little to no interest in the active side of their treatment.
Don’t think you can change this by giving them a few sessions of manual therapy and then all of a sudden they will buy into what you want them to do. Giving a manual therapy ‘addict’ more manual therapy isn’t going to help them want it less. ‘One last fix’ is often used as an excuse by many addicts but it often fails as it just perpetuates and continues the vicious circle of stimulus and reward. One last fix is never one last fix!
To break a habit a clean break is needed with support, motivation, and sometimes a distraction. The best way to move someone away from manual therapy is not to give them more but instead give them something else to focus on, like exercise.
Finally to wrap this up please remember that you don’t need ANY treatment to keep patients coming back. Also, remember that focusing on getting patients to come back is actually a pretty shitty way to work. Instead, physios should be focusing on getting patients better and NOT needing to come back as quickly as possible. Also, remember that patients will return to a therapist who they trust and believe is able to help them with the issues and problems they have, and this has NOTHING to do with what type of treatments you do, or don’t use.
So I’ve been involved in a few more frustrating discussions around manual therapy recently mainly about why some therapists justify using it. During these discussions, therapists often tell me they use manual therapy as a form of graded exposure to painful movements or tasks and it helps patients return to normal function and activities better. Well, this is not actually correct and manual therapists need to find another excuse to justify their rubbing, poking, and pressing because it’s not graded exposure.
Now manual therapists often come up with some weird, wonderful and whacky reasons for using their techniques, some less plausible than others. Things such as releasing fascia, breaking adhesions, freeing up muscle knots, or reducing muscle spasm. So when some say manual therapy is a form of ‘graded exposure’ it sounds not only plausible but also scientific, evidence-based and contemporary. However, it’s just not true, manual therapy is not a form of graded exposure treatment.
Many therapists have poor understanding and rather skewed ideas of what graded exposure treatments are. Often they confuse, bastardise or completely misrepresent graded exposure to explain or justify the use of their treatments.
For example, therapists often tell me that they use taping, dry needling, manipulation, or joint mobilisation to allow patients to do movements or tasks with less pain, fewer restrictions, and less fear and anxiety. They tell me that by performing some form of passive treatment to a patient in pain it opens the window of oportunity and allows them to move more frequently and therefore is a form of graded exposure therapy.
Graded exposure is a specific behavioural treatment designed to reduce or remove fear, anxiety, and avoidance by exposing a subject to the fearful stimulus. Graded exposure is performed by exposing the subject to the stimulus, not by removing or reducing as many manual therapists seem to think.
For example, if you have a fear of spiders, you don’t become less fearful of spiders by avoiding them. Also if you are terrified of spiders being exposed to some fluffy bunny rabbits also won’t reduce your fear of spiders, it has to be context-specific.
This is no different with pain on movements or activities. If you are avoiding bending forward because it hurts your back and you are worried, scared, or afraid that it’s harming you, having some needling, massage, or a manipulation first and feeling less pain when you bend forward won’t reduce your fears of bending when the pain returns.
Likewise, if you are afraid to lift your arm up overhead because it gives you a sharp catch, having a nice young attractive physio apply a Mobilisation With Movement or a Scapula Assistance Test as you reach up which reduces the catching sensation this won’t help you with your anxiety or reluctance to reach when they stop doing these things.
Symptom Modification ≠ Graded Exposure
Simply put manual therapy is NOT a form of graded exposure treatment, its a form of symptom modifying treatment which is a completely different argument (ref). Now you may be thinking this is just Meakins being pedantic over semantics, but its an issue that is causing some misunderstanding and misuse of two very different approaches to patients in pain.
For example, if you have a patient who you assess not to be displaying any signs or symptoms of fear or avoidance to movements or tasks that hurt. That is they are continuing on with daily tasks, work, and sports despite their pain, and in the exam, they show no signs of anxiety, apprehension or reluctance to move despite their pain, then I would say modifying their symptoms with some passive interventions could be useful, it’s not essential or necessary but it could be an option.
However, for these kinds of patients, I prefer not to apply manual therapy but rather I prefer to discuss activity and exercise modifications, even advising some short periods of rest. Yes, you heard me, rest, it’s not a dirty word and it can be an effective treatment for some people in pain in some situations if not used for long durations (ref). Of course, I will also look to load them in ways that don’t provoke or aggravate their current symptoms if possible.
However, if you have a patient in front of you who you assess is displaying some signs of fear, reluctance, anxiety and avoidance with movements and tasks because of their pain, then modifying their symptoms with manual therapy or any other passive treatments may NOT be the best thing for you or them to do.
Despite it being wanted by these patients and despite it being far easier for therapists to do this, removing pain when there is no need may actually be more harmful than helpful. If you want to help a patient reduce their fear, anxiety or apprehension of a painful movement, or if you want to give them control, confidence and get them to return to a task or an activity they have stopped, then they will need graded exposure to it… but without first reducing, removing or modifying their symptoms.
Hardest thing to do!
Getting patients to do the things they fear or are avoiding the most is without doubt one the most challenging, difficult and unnerving things a therapist has to do, and why I don’t think that many actually do it.
To be able to recognise who does and who does not need to be pushed into pain, when it is safe to do so, and how far to take it, takes a shit load more skill, effort, experience, confidence, and bravery than using any manual therapy or symptom modification treatments.
One of the biggest misconceptions I hear about therapists who don’t use manual therapy to reduce patients pain but rather push them to do things that hurt them a little or are challenging them is that they are cold, discompassionate and uncaring, this is complete and utter bull shit.
To be able to calmly and confidently get a patient to do something they don’t want to do requires far more skill in communication, rapport building, and motivation than anything else. Believe me when I say its no easy task to ask a patient to do something that hurts them, in fact, its the hardest thing to do with you always questioning and second-guessing if you are pushing them too much, too hard, worrying about flaring them up and then losing their trust and confidence in me.
It was so much easier and simpler when I could just push, poke and pamper all my patients, telling them to avoid, reduce, or stop doing things that hurt, but I found this didn’t sit well with more but more importantly it don’t actually help many people get any better or back into doing the things they wanted.
So that’s my two cents on how manual therapy is NOT graded exposure but symptom modification which works through completely different mechanisms.
Manual therapy and most other symptom modification techniques will always have small effect sizes, last very short periods of time, be unreliable in who they work for and don’t work for, and in my opinion, are generally not worth the time and effort for most issues.
So if you are using manual therapy and are telling patients, other physios, or yourself that its a form of graded exposure therapy, its time to find another excuse.
In my last post, I discussed how many of us have low tolerance to many things that are hard, difficult, or painful. In this piece, I want to discuss how motivation won’t help you do things that are hard, difficult, or painful, and it doesn’t matter how motivated you think you are, I know you are a work-shy, bone idol, lazy loafer.
Now before you go ranting in the comments section let me explain why all of you are inherently lazy. Its because all humans are lazy, even the most devoted, dedicated, ardent SOB deep down is a lethargic lay about because evolution has taught us that conserving energy whenever possible is really smart.
This is because in a world where energy is finite and survival based on avoiding being eaten or starvation, conservation of energy is paramount, and this applies all life on our planet. For example, you don’t see many lions going for a morning jog before a day hunting, or a gorilla doing some press-ups to keep buff for the ladies. In nature, you will not see anything do something it doesn’t have to. And this is really no different for us humans.
To get a human to do something that requires a significant expenditure of energy they need a stimulus to act. This use to be things like fleeing from predators, chasing something to eat, or occasionally an urge to reproduce. It’s these basic instincts that motivate us and everything else to move, referred to flight, fight, and f**k
These days to get a human to expend energy without these basic instincts is really, really hard. Many know that regular exercise is beneficial for them, yet despite knowing this, many don’t do any, and it’s getting worse.
A recent depressing report found that many adults in the UK now sit on the toilet longer than they exercise per week. Our species is simply devolving away from exercise as we have lost most of our motivation to move.
Most of us in the modern world live in secure safe environments, with easy access to ample amounts of calorie-dense food and even easier access to members of the opposite sex (thanks tinder).
Basically, we have lost our basic flight, fight and f**k motivators to expend energy. And many try to replace these with other motivations. However, motivation is a really weak stimulus to get anything done consistently.
Simply put without flight, fight or f**k, motivation for anything else is very limited and very finite. In fact, motivation runs out extremely fast and very quickly for most of us.
Yet motivation is often hailed and promoted to be the answer to getting us moving more and exercising regularly. You only have to go on Insta-google-face-tweet-book to find a gazillion personal trainers, doctors, physios, and other exercise gurus giving their motivation tips, pictures, and videos to encourage humans to move and exercise more.
Personally, I think motivation is about as useful as a chocolate teapot. That’s because motivation only works when everything else is ok. Most people are motivated to exercise when they have no other major issues, hardships or problems in their lives.
Motivation is weak, discipline is key.
We should all move away from using motivation and focusing more on discipline. Many think motivation and discipline are the same things, they are not.
Motivation operates on the need for particular mental or emotional states to complete a task. Discipline is independent of and separate from moods or feelings.
Motivation is about trying to like doing stuff. Discipline is about doing it even if you don’t like it. Motivation will quit on you in the presence of hardship, discipline won’t!
Discipline is a key skill to master in life, and once you do you can master anything, even regular exercise. Once discipline is a regular trait you won’t need motivation to exercise or do anything else hard, difficult or awkward.
Smell Of It
Of course, if you have discipline and motivation together that’s a great bonus, but don’t rely on motivation as it will run out very quickly, even if you really like doing exercise, and I know this only too well.
I love to exercise in lots of different ways, rugby, boxing a bit of BJJ and these days mainly running and lifting heavy things. I’ve done these for as long as I can remember. I love the feeling, the rewards, and even the smells of exercise.
Yet despite this, there are many, many times when my motivation to exercise just isn’t there due to a bad day at work, feeling tired, bad weather, an ache, a busy schedule, the list of motivation thieves is long. All these things often and regularly reduce or completely steal my motivation to exercise.
However, despite no motivation, I still go and lift, or run not because I want to, because I need to. This is the difference between motivation and discipline, this is what I think needs to be educated, promoted and focused on more in the general population and our patients. More need to understand that it is still possible and essential to do things even when you don’t want to.
I know many of you will think I am yet again being too simplistic, too harsh, too uncaring towards those who don’t exercise regularly. I’m not, I’m just trying to highlight that trying to increase someones motivation to exercise is ineffective and insufficient and something else needs to be done.
I am well aware that this is no easy task and there are huge barriers to negotiate and overcome to do it, but there are ways to help improve discipline. Things like planning, setting routines, targets, rewards, back up plans and having a good support network. But without a doubt, the best way to start developing discipline is to start with small steps.
Any change is hard to tolerate but a small change is less hard.
There is an old tale that if you put a frog in boiling water it will jump out immediately as the change in temperature is too much. However, if you put a frog in warm water and slowly heat it up it won’t jump out as you bring it up to the boil. As nasty as this sounds the moral is don’t try to change too much too soon. Small changes done consistently can lead to big changes over time.
Research has looked at exercise compliance within physiotherapy and found it to be very low due to many multifactorial reasons (ref, ref, ref). I also know some research has come up with suggestions of how to address these (ref, ref, ref) and I think these recommendations are good. However, they tend to overlook or ignore the effect of an individuals discipline when it comes to exercising consistently.
Fun Or Functional
As a physio, I give exercises to patients because they address their problems and issues, such as a lack of strength, capacity, or confidence in a movement or a task. I don’t initially give exercises to my patients because I want to get them fitter or stronger, or because they enjoy them, or fit with their preferences.
Don’t get me wrong if I can find an exercise that a patient enjoys doing then that’s a bonus, but we don’t live in a perfect world. To be honest not many of my patients get overly-excited about the squats, deadlifts, or overhead presses I ask them to do.
I know some therapists think this is terrible, abhorrent, non-patient centred and that I should try harder to find exercises or activities that my patients like to do, but this is just not always possible, or practical, or the best thing to do.
Most busy physios simply don’t have the time or resources to explore all the patient’s preferences, potential barriers, or issues of why a patient may not do an exercise. Nor is it possible or practical for most physios to play around experimenting with different exercises or movements to find one that best suits the patient’s preferences the best.
Instead, most physios need to find exercises that are known to be effective at improving strength or capacity, that will do the job quickly and efficiently, and that a patient can do simply. This often means for me the exercise is a simple basic well-known and trusted one such as a squat, deadlift, or overhead press, not sexy, novel, exciting, or fun, just effective.
More need to realise that motivation is weak and discipline is key if they want to improve their health or have a better quality of life. Things such as eating healthier, going to bed earlier, and exercising more all require the trait of discipline. This doesn’t mean it has to be a complete ball ache or military regime all the time, but it does mean that life has to be occasionally hard, difficult and painful at times.
We all have different tolerances to different things such as how long we can concentrate, exercise, or put up with some people. I for one know that I have a very low tolerance for those who wear barefoot toe-shoes, have man buns, or take offence at everything they disagree with.
Our levels of tolerance both physical and psychological are due to many things such as our genetics, previous exposure, experiences, and even our education. Some people can tolerate exercising more than others because they do more of it, some can tolerate stress better due to previous experiences with it, and some can tolerate other people better because they have been taught to.
However, it is clear that more of the human population is becoming more intolerant of many things such as foods, textiles, and medications. And more people these days are also less tolerant of change, diversity, and differences of opinion, and many are intolerant of any difficulty or discomfort in their lives.
Our World Today
Most of us living in the modern developed world have a life of convenience and comfort. A world where we have ample access to food, water, shelter, and wifi. A world where you have technology and gadgets to make your life easier and effortless. A world where you can buy a device to put your socks on in the morning, a duvet that makes your bed, or a machine that opens your jars. We don’t even have to go to the supermarket anymore to lift our jars off shelves and carry them in a basket with home delivery and even unpacking services on demand.
We are living in a world where effort and exertion have mostly been removed, where any effort, struggle or strain is considered unnecessary and often avoided. Don’t get me wrong, this modern-day lack of difficulty does has some amazing positives, I for one am not complaining about my 5G wifi signal, my central heating, or my online grocery delivery. But the sheer amount of convenience and ease we have in our lives today also has drawbacks.
One of these drawbacks is that we have lost sight of what is actually difficult, hard, or inconvenient. What we consider challenging these days simply is not. Missing a meal, losing your wifi signal, or having to walk up the stairs because the lift broke are not difficult or serious issues, yet our modern lifestyles and lack of exposure to them often make them feel so.
Our Pain Today
This I believe is no different from our experiences of pain. Having a sore knee, an irritated shoulder, or some low back pain is often not a serious medical issue that needs to be assessed and treated. Most of our grandparents would not have seen a doctor or therapist for such things, instead, they would have just carried on understanding that things hurt from time to time.
If we were to look back just 2 or 3 generations I bet we would see that most people would NOT seek medical attention for back, knee or shoulder pain unless it was serious or had other sinister signs or features. This was of course due to access to medical services being far less back then, but I also think it was due to a difference in culture and attitude towards pain as well.
I often ask myself when I have a pain or an ache, what would my grandad do… and most of the time it would be to ignore it and crack on!
Many think that all pain and discomfort should be reduced or removed immediately. I think a lot of things that hurt just need to be tolerated and endured for a period of time. I truly believe that by reducing and removing pain too soon, too quickly, and too unnecessarily healthcare is contributing to society becoming less and less resilient to pain.
Earn Your Health
And if you want your body to look after you and give you less pain, you need to look after it. Many think being healthy is easy and an automatic right. It’s not. Of course, there is the lottery of genetic luck to get through first to avoid any congenital disability or disease. But if you have come out of that with good fortune then good health has to be earned with some hard work, self-control, and discipline, and the inconvenient truth is that many musculoskeletal conditions today are often consequences of our convenient lifestyles.
However, regardless, of why things hurt from time to time the key point is that often nothing needs to be ‘done’ for it other than reassuring the individual that it’s not serious, it will ease with time, and they will not harm themselves if they feel some pain on movement and they should try to carry on as normally as possible.
However, as much as some patients don’t like hearing this, a lot more healthcare professionals don’t like doing this even more. Many healthcare professionals just don’t feel comfortable telling people in pain that nothing needs to be done for either financial or egotistical reasons. Personally, I think many musculoskeletal conditions are over-treated with healthcare professionals pandering to patients while natural history makes them look good.
And please dont think this is just me being mean, cold, uncaring, or discompassionate, this is just me being open, honest, and frustrated at a system that I think is going the wrong way and screwing things up right royally. Healthcare has undoubtedly helped humanity hugely by reducing disease and pathology and increasing our lifespans. But healthcare has also inadvertently caused harm by making humanity less resilient and less tolerant to pains and problems due to its over-treatment.
If you want some proof then go look at the BMJ global burden of disease studies you can see that low back pain now consistently causes more disability and costs society far more than any other medical condition across the world, and this is despite many advances in our so-called modern pain management treatments.
In summary what healthcare is currently doing for musculoskeletal pain just isn’t working and something needs to change. Personally, I think this should start with more healthcare professionals recognising that they over-treat it, and all humans recognising that pain in life is inevitable, but suffering it is optional.
I see more and more fitness and rehab professionals promoting the message of ‘don’t load a dysfunction’ and it annoys the hell out of me. This mantra displays a complete lack of understanding of the complexities of human movement, the multifactorial nature of injuries and pain, and the many uncertainties of rehab and recovery.Not to mention that no one can tell you what the hell a dysfunction actually is.
This message also has some negative and possibly harmful ramifications for those who love to exercise but even more annoyingly creates unnecessary barriers and restrictions for those who don’t like to exercise. So I want to spend the next 5 minutes discussing why I think many of these influential, well-known, and highly respected fitness and rehab professionals are wrong, and make a case for why we should be actually loading these so-called ‘dysfunctions’.
So first what is a ‘dysfunctional’ movement? Despite many claims, we actually have very little evidence that tells us what movements, activities or exercises are bad, dangerous, or harmful for us… if indeed there are any at all.
Many will claim that they can spot a dysfunctional movement or exercise just by looking at it. But the fact is when it comes to observing movement “beauty is in the eye of the beholder” meaning that what can look ugly and problematic for one person, can look perfectly fine to another.
The notion that we can tell what is good or bad movement just by looking at it is frankly nonsense. This overly simplistic and reductionist way of classifying human movement based on an individual’s observation alone needs to stop.
To put this as simply and clearly as I can… how we move is dictated by many things such as 1) individual factors; such as age, skeletal morphology, previous experience, current confidence, pain levels and so on. 2) task factors, such as the load, speed, intensity, complexity and so on, and finally, 3) environmental factors such as moving while being observed, or in a competitive situation, or using different equipment etc etc etc.
Therefore how we perform an exercise or any other movement is always going to be influenced by these many other factors, meaning that very often no two people will move the same, and often the same person won’t move the same way twice.
So when assessing any movement we need to recognise that we are all built differently and come in all different shapes and sizes and so we can not all move the same. Variations in our skeletal structure and geometry such as limb length and joint shape and angulation will influence how we move. For example, femoral length and pelvic geometry hugely affects how an individual squats as shown below (ref, ref).
So just because some ‘movement specialist’ with short femurs, open hip sockets, and a touch of genetic hypermobility can fold up like a deck chair when they squat… don’t think you will ever be able to if your bony geometry and genetics are completely different! And just because some ‘supple leopard’ can reach up between their shoulder blades and scratch the back of their own eyeballs, don’t think you will be able to if your shoulder and thoracic bony geometry won’t allow it (ref, ref).
It is important to recognise that what may look like ‘dysfunctional’ movement could be due to very non-modifiable genetic and or skeletal factors. However, this is very difficult to determine clinically without a lot of detailed, expensive, and unnecessary scanning and imaging, but it should always be considered nonetheless.
Now, of course, not all movement restrictions are due to non-modifiable bony factors, many can be due to the more modifiable soft tissue factors. Again determining if a movement restriction is modifiable or not can be difficult, but you can usually begin to realise that you may have some non-modifiable factors limiting your movement if you have tried to work on improving your movement for a few months and nothing has changed.
If this is the case then it may be time to start accepting that your movement isn’t going to look like someone else’s because of factors outside of your control and try not to get too frustrated or disheartened by your lack of progress in trying to imitate some flexible guru with completely different anatomy.
Our movements are also hugely affected by the task being done, and again this tends to be ignored by many movement gurus. For example, how an individual bends over to pick up a box of tissues from the floor will be, and should be, completely different from how they bend over to pick up a concrete slab from the floor.
Having someone move the same way regardless of the task’s intensity, speed, and purpose is simply batshit crazy, yet its something I see being promoted by many every day. You simply do not need to bend over the same way to do everything, in fact, this is inefficient and not functional.
You just do not need to brace your abdominal and pelvic floor muscles or keep your spine in neutral before you reach down to pick something small and light off the floor. Rather than helping and improving movement this can make many people move less and worse as they become overly focused, stressed, worried, and hypervigilant on small, tiny, innocuous things that are just not worth worrying about.
Variation in movement patterns is perversely something a lot of ‘movement specialists; understand or feel comfortable with. And movement variation occurs all the time and depending on the task and the load is much more useful than movement restriction (ref, ref).
Now, this is not to say that restricting variations in some movements, in some people, some of the time can be useful because it can. In some situations, in some circumstances, it can be very helpful to coach and constrain movement to help a person move more ‘efficiently’ during some tasks such as heavy repetitive lifting.
However, do not get fooled into the common belief that applying these movement constraints magically or significantly reduces the risk of injury. Many of our common assumptions about injury risk are being challenged more and more, with many studies in occupational manual handling showing how postural ergonomic and lifting advice doesn’t significantly reduce the incidence of back pain as we first thought, and in fact, may even be contributing to it. (ref, ref, ref, ref)
Finally, we need to consider the environment as a confounding factor when we assess movement. As therapists and trainers, we often assess people moving in controlled, constrained, and ultimately false environments. Therefore any of the so-called movement dysfunctions we may or may not see here, may or may not occur in other settings or environments. We also need to recognise that just the effect of observing a subject move will affect how they move.
For example, how normally do you think a patient will be moving when being scrutinised in a cubicle, or gym when they are half undressed and feeling a little anxious or nervous? Do you think you will see the same movement strategy will be used when a subject is asked to perform drop landing off a box whilst being observed compared to when they are on a cold wet football pitch on a Tuesday night in Stoke, jumping for a ball whilst dodging an opposing player?
It’s not that simple!
So hopefully I have highlighted how all of our movements are based on many variables and what we think may be abnormal or dysfunctional could just in fact be normal and even advantageous variations.
We also need to recognise that what we think are movement‘dysfunctions’ may actually be optimisation strategies in the presence of pain, fear, or a lack of tolerance and capacity. Personally, I think this is one of the most common reasons I see people moving differently or awkwardly.
Why I load ‘dysfunctions’
So often it’s not the movement that needs to be corrected, it’s the pain, fear, lack of capacity or confidence in the movement that does. This is why I load so-called ‘dysfunctions‘.
I have realised that if I focus more on increasing an individual’s capacity and tolerance to so-called ‘dysfunctional’ movements, they often stop looking as ugly and awkward, and stop feeling as uncomfortable or difficult. When you build a person’s comprehensive capacity to move you often find the individual self-organises their movement strategies to become more efficient without you having to do much at all.
This is why I dont use any specific motor control drills or fancy coaching techniques anymore, Instead, I simply give a person the chance to build capacity and confidence in the movement and let their system gradually self-organise and find its most preferred strategy to get the job done. This often makes awkward ugly looking movements look much more efficient and ‘pretty’.
However, there have been times when I have also found that the observed ‘ugliness’ of a movement does not change, but again that also doesn’t really matter to me anymore either. As I said at the beginning of this blog ‘beauty is in the eye of the beholder’ and who am I to say what is an ugly movement or not.
All that I am really concerned about is does this movement feel comfortable and efficient to the person doing it? As far as I am concerned you can have the ugliest-looking movement in the world as long as you are confident, comfortable, and have the capacity, both physically and psychologically to tolerate it!
So that’s my two cents on why I load ‘dysfunctional’ movements and why I disagree with many of the ‘movement specialists’ gurus on this topic. Remember that there is little evidence to say what is and what isn’t a dysfunctional movement but it’s damn well NOT just what it looks like to an observer.
So the NHS has reached 70 recently, but what does the future hold for it? The report ‘How Good is the NHS? highlighted that overall the NHS did OK, and considering it has fewer staff and spends less on health care per capita than the majority of similar counties we should be hugely proud of our NHS and give ourselves a big pat on the back.
But the NHS is far from perfect, in fact, this report also highlights that the NHS fails or is poor at treating a long list of conditions such as;
These non-communicable diseases place a huge burden on the NHS financially and through hospital admissions, but you may be thinking what have these got to do with physiotherapy and me? These are all medical conditions and I’m a neuro, orthopaedic, respiratory, community, paediatric, or some other physio; These conditions are not my problem or responsibility. Well, they are.
Physiotherapy should be at the forefront of prescribing the best available healthcare and this includes exercise. We are one of the few healthcare professions (and I use that term ‘profession’ lightly in this respect) that has significant face time with a great many people that are in need of guidance, signposting, and education of the importance of exercise. However, a recent paper by Lowe et al 2017 found not only do UK physiotherapists have a mediocre knowledge of the very basics of exercise, but the vast majority do not do the bare minimum amounts of what is considered necessary to maintain a healthy life.
Physical inactivity has a significant impact on morbidity and mortality (Lee, et al 2012). Physically inactive people spend 38% more days in hospital and use healthcare resources significantly more than healthy active people (Sari, 2009). Many of these inactive people turn up in our physio clinics or outpatient departments seeking our help, often due to the consequences of their inactivity which start to manifest and affect their ability to function. But how many physiotherapists discuss, encourage or facilitate these patients to engage in basic lifelong exercise?
Well in the recent Lowe paper they found that a favourable 77% of UK physios discussed exercise with their patients, and 66% routinely delivered brief exercise interventions in their treatments. Unfortunately, the paper does not detail what these brief interventions are, but I suspect it is the usual 3 set of 10 reps bollocks with a flimsy yellow theraband, which seems to be the default go-to exercise prescription for most physios.
However, far more disappointing is that only 16% of physios correctly answered the questions about the content of the physical activity guidelines. This is just inexcusable. These guidelines are not hidden in some secret bunker, they are freely and easily available through various channels (DoH, 2011, WHO, 2017, ASCM, 2011) and should be instantly quotable by all physiotherapists. It’s such basic knowledge.
So where does the fault lie that so many UK physios don’t know this stuff? I guess we can blame the universities? And, yes some undergraduate courses don’t teach or have a module covering exercise in any great detail. And if they do, how much do the students engage with it and to what extent is the importance of exercise promoted? Very little I suspect.
Really the fault lies, with physiotherapists themselves not bothering to learn something that will, if used correctly, change the lives of all the people they see, as well as eventually save the NHS and wider society billions of pounds and develop a more productive, able population.
For example, in 2002 obesity alone cost the NHS £2 billion (Butland et al 2007) and by 2006 this was over £5 billion (Scarborough et al 2007). Now I’m not suggesting exercise alone can address the obesity issue, but it is known that those who exercise more often tend to be more diet and health conscious. Unless we get this under control the NHS is heading for a tsunami of health-related issues on this one issue alone. Could the NHS survive when projected costs of obesity alone are expected to be in the order of £10 billion by 2020? Probably not?
We, therefore, need an NHS that is proactive in addressing and combating these issues before they occur, not wait until a population of people waddle into our hospitals with arthritic knees and low back pain, or flood our A+E departments with strokes and heart attacks. As physiotherapists, we need to start looking at how we can help prevent these conditions before they occur, and not only treat them when they do, and the best we can do this is to promote exercise more… a lot more!
A lot of physiotherapists are quite happy to spend hundreds even thousands of pounds on some poorly evidenced course so they can become ‘experts’ in manipulating joints, sticking pins into people, or releasing tight facia, but would not dream of going on a course that teaches them how to prescribe the basics of an exercise program that can be safely adhered to?
To make matters even worse is this latest campaign from the CSP, our so-called professional body called “Love Activity, Hate Exercise?”. Now, this campaign may seem on face value to be well-intentioned but it sends out completely the wrong message. Increasing activity is a good start but it is NOT sufficient to reverse the effects of sedentary behaviour and poor lifestyle choices.
A gentle stroll or some fannying around in the garden now and then will have little or no effect on promoting meaningful physiological adaptations needed to maintain or improve health. The CSPs own website doesn’t even state the correct WHO guidelines for physical activity stating that; ‘only 50 per cent of UK adults do the recommended minimum of 150 minutes of moderate to vigorous exercise each week’.
Well, what about the 2 sessions of high intensity and/or whole body strengthening exercises per week that are also recommended by the WHO? Why have these been omitted? Is this ignorance or are we too frightened of scaring or upsetting people to tell them they need to get up off their lazy arses and do some hard intense exercise a few times a week?
Not only do a lot of physiotherapists not know the recommended amounts of exercise, even more, don’t do any regular exercise themselves. In the same Lowe et al paper, only 38% of the physiotherapists who responded reached the minimum recommended amounts of exercise, this is even less than the general population, and we as a profession are supposed to be leading by example.
Again it seems that many physios are quite happy to poke, massage, pin, tape etc. but to get them to do some exercise themselves and show their patients a healthy, fit, strong person is just too much to ask. If the results from the Lowe survey are applied across all of the physiotherapists registered in the UK, then some 32,000 physios are doing little to no exercise, and they then have the audacity to try and tell their patients to do more. Is this something as a profession we should be proud of? Hell no!
I, for one, hate seeing overweight, unfit physiotherapists struggling to bend down to examine a patient, to climb some stairs, let alone trying to demonstrate an exercise to their patients; simply put there is no fucking excuse for this.
I do appreciate that regular exercise is not easy for everyone to do, or stick to, but it needs to be sold to patients and undertaken by us all as healthcare professionals. It needs to become part of our daily lives just as brushing our teeth, washing our faces, or getting to work on time is; it needs to become part of our daily routine and a positive habit.
Yes, regular intense exercise is hard to do, but its a hell of a lot easier than having to live with the after-effects of a stroke, or a heart attack, or type 2 diabetes and becoming a burden to your family and wider society.
So to all the physio’s out there, put down that cream cake or that slice of pizza, don’t have that 3rd glass of wine or that 4th can of larger, get up off your lazy arse and go do some intense, challenging exercise, and do it often. Be the example and motivation for your patients, lead by fucking example.
As the great philosopher, Bertrand Russell once said “people would rather die than think, and most people do’ just replace ‘think’ with ‘exercise’.
Thanks for reading
Bio: Nick came to physio late in life after 18 years as a London Fire Fighter and qualified in 2005 from Keele Uni. He works at the Robert Jones & Agnes Hunt Orthopaedic Hospital in deepest darkest Shropshire. and also has a private clinic at a climbing centre called The Boardroom (www.theboardroomclimbing.com) where he treats climbers with a wide variety of MSK problems.
There isn’t a month, a week, sometimes a day that goes by where I don’t get accused of being biased on social media, the last one just yesterday. When people point out my bias it’s often not a shock or a revelation to me, as contrary to popular belief I am mostly aware of, and comfortable with, most of my biases.
However, in an attempt to avoid repeating myself time and time again when I next get accused of bias I thought I would write a blog on it. First I thought I would look at what bias is, how it can affect us all in some strange ways, but more importantly how some bias can be positive.
Bias is usually defined as “an inclination or prejudice for or against someone or something in a way that is considered unfair”. Bias is a human condition and no-one, and I mean no-one, is infallible to it, not even the best critical thinking academic online social media physio guru who likes to point them out in others all the bloody time.
Simply put if you have a brain, you have bias. However, bias is often seen as a negative or harmful trait, and yes a lot can be, but despite its reputation some biases can be good and advantageous.
Bias can be explicit or implicit meaning we have them intentionally or unintentionally. Usually, our unintentional implicit biases are the tricky little buggers that tend to make fools out of us, and before I discuss some positive biases I want to first go through some of the sneaky implicit biases can make you look like a dumbass!
We all love to agree with people who agree with us and it is why we only tend to talk to and hang around with people who hold similar views and ideas. Confirmation bias is without a doubt one of the most difficult bias to be aware of and then overcome, as most of us tend to be put off by and avoid individuals or groups who hold different views and opinions. When we do engage with those we disagree with we often tend to blame them for the uncomfortable feelings we get rather than recognising it is our own confirmation bias making us feel insecure.
A perfect example of confirmation bias that I hear and see daily is when many moan about how nasty and confrontational social media is. Well, there is no doubt social media can be nasty at times but mostly it’s not that bad, it’s just that it’s not the nice, comfy, cosy, safe, echo chambers many are used to. Social media is a public domain where people will disagree with you in various different ways, and personally I think more need to stop whining about a difference of opinion online and start recognising that it’s their own confirmation bias that is being kicked around a bit.
Status Quo Bias
We all hate change, everyone does, it makes us feel uncomfortable and awkward no matter how flexible, open, and receptive to change you think you are. Humans are evolutionarily hardwired to be apprehensive, wary, and resistant to change, this often leads us to make choices and decisions that try to keep things the same. A classic example of this status quo bias that I see on EVERY course I do is that without fail is about 99% of people will sit in the same place on the second day despite having a choice to go to a different location.
Status Quo bias is also why most clinicians stick to their preferred assessment and treatment choices instead of changing or abandoning them when confronted with evidence to do so. The destructive nature of this bias in healthcare is the unwarranted assumption that change will make things worse and that if it works then why do I need to change.
Have you noticed that as soon as you finished that weekend pelvic course suddenly everyone who came into the clinic had a pelvic asymmetry? This is a classic example of observational bias, the effect of suddenly noticing things we didn’t notice before. This is not because these things are appearing more frequently, it’s just that you’ve been primed to look for them.
The trouble is, most don’t recognize this as a bias and actually start to believe these items or events are happening with increasing frequency. It explains how some therapists start to think things like poor posture and other modern-day behavioural habits are to blame for issues such as an increase in pain levels in the general population. It’s also why we often think that the appearance of certain things or events can’t possibly be a coincidence even though they are, such as when our patients get better after seeing us.
We tend to pay more attention to bad news and it’s not just because we’re morbid, its because we perceive negative news as being more important or profound. We also tend to give more credibility to bad news, perhaps because we’re suspicious of constant claims to the contrary. Also again evolutionarily, heeding bad news has tended to be more beneficial and adaptive than ignoring good news (e.g. ” sabre tooth tigers suck” vs. “this berry tastes good”). However, today, we run the real risk of dwelling on negativity at the expense of positivity and this is true in our day to day lives, the media, and of course healthcare and physiotherapy.
In the world of research, a positive bias is a negative thing as it refers to the preference for publishers to publish research that has a positive or eventful outcome over research that has an uneventful or negative outcome. This can lead us to make errors in our judgement and thinking when choosing treatments and it is a huge problem in all aspects of healthcare, physio included. Without publishing the research that shows little, no, or even detrimental effects we tend to get a skewed view of the effects of some treatments such as dry needling, manual therapy, symptom modification procedures and so think they are more effective or safer than they actually are.
My Positive Bias
Now to finish this blog I want to discuss the bias that I get most accused of which is my clear, obvious, and intentional bias towards the use of exercise and activity over and above passive treatments such as manipulations, massage, electrotherapy, taping, needling etc for all painful musculoskeletal conditions and complaints.
Although the evidence on exercise for helping many painful conditions cannot be called strong and it does not consistently outperform all passive treatments, I don’t care! If two treatments work the same for pain, but one has greater impact on an individuals health, function, and many other secondary things, then for me it’s clinical unethical and immoral to not have a bias towards exercise and activity!
I will be the first to admit that the how and why exercise-based interventions help, or don’t help, painful conditions is not well understood, and I am aware that the process of doing the exercises may be more beneficial than the outcome for many people in pain.
We know exercise can create both physiological and psychological effects and trying to determine which of these is working more or less for some is near on impossible. However, just because we can’t say what is or isn’t helping with exercise-based interventions, doesn’t mean we can’t use them, and let not forget that all the same uncertainties surrounding ALL other treatments for pain such as manual therapy, electrotherapy, tapes and needles.
The argument I get a lot is that we should use both active AND passive treatments combined, however I disagree! The addition of passive modalities to exercise doesn’t seem to significantly enhance the effects of exercise when given alone! Also I think using too many treatments all at the same time can confuse and complicate things and distract time and attention away from them weaken the effects for many!
So it is these factors which is why I have now abandoned all passive modalities from my practice as a physio completely and I don’t regret it or miss it one little bit… far from it, I wish I did it sooner!
My advocacy and promotion of abandoning mana therapy is what often causes a lot of anger and accusations of bias from many who continue to use them, even more so from those who teach them. This is often due to their own biases and so to combat this they are quick to accuse me of my own bias whilst ignoring their own.
Having a bias doesn’t automatically make an person or action bad, harmful or invalid. For example, I have a very strong bias that all racism and sexism is wrong and abhorrent. I also have a strong bias that putting your hand into a fire is not sensible. Are these bias flawed? Of course not!
Some biases are formed on information so strong and concrete that they are positive biases, and those that attempt to appeal to the exception or the middle ground and argue that we need to be as critical of all our biases is simply not true.
So, if someone has a bias towards exercise over passive treatments this is in my opinion a positive bias and one that I am proud to have. And to be honest its a bias I wish more Physio’s and healthcare professionals had. Could you imagine what our healthcare system would look like if every doctor, surgeon, therapist, nurse, assistant had a bias towards using physical activity and exercise over drugs, surgery, bed rest, tapes, braces, needles, massage, etc?
In summary, if being biased towards exercise is wrong, then to put it simply, I don’t want to be right!
Healthcare can be a bit like a playground at times with lots of clinicians swinging from treatment to treatment, patients feeling like they’re on roundabouts going around in circles, and all of us have felt the see-sawing highs and lows of trying to help people with pain and disability.
As a shoulder ‘specialist’ one area I have had many highs and lows with over the years is sub-acromial shoulder pain. I find it a fascinating yet infuriating condition, not only due to the difficulties in its diagnosis but also in its uncertainty in how to manage it.
One uncertainty I have had for a long time is what role does surgery have, in particular, arthroscopic sub-acromial decompression surgery? Who is best suited for this operation which involves shaving the bone of the acromion and the removal of the sub-acromial bursa and sometimes the coracoacromial ligament which is believed to reduce compression forces on the rotator cuff underneath?
I have discussed my concerns and issues with this operation before, having seen it performed too often, too quickly, and seen too many patients worsen afterwards. But I have also seen some great success and some very satisfied patients with this surgery. The questions are why do some do well and others not? Is it the surgery, the rest and rehab after, or maybe its something else?
To try and answer these questions a highly anticipated paper was published a few weeks ago in the Lancet called Can Shoulder Arthroscopy Work or CSAW. It’s free to access and I urge you all to read it as I believe it to be one of the most important papers on sub-acromial shoulder pain published in a decade.
This large, rigorously conducted, blinded randomised controlled trial compared three groups of patients with sub-acromial shoulder pain who had failed conservative treatments. One group served as a control and were not given any further treatment at all, being followed up at 6 and 12 months using the Oxford Shoulder Score.
The other two groups had arthroscopic surgery on their shoulders. Half were randomly allocated to have a diagnostic arthroscopy only which only involved placing the surgical instruments into their shoulders under anaesthetic and then removing them. The others had a ‘routine’ or usual arthroscopic decompression which involved shaving of the acromion, +/- removal of the bursa and the coracoacromial ligament as deemed necessary by the surgeon.
All the patients and those involved in the follow-up care were blinded so no-one knew who had the arthroscopy or the decompression, and both groups had the same aftercare and physiotherapy treatment. They were also followed up at 6 and 12 months using the Oxford Shoulder Score just like the control group.
The results below show that there is NO significant difference between the two surgical groups, demonstrating that shaving the acromion and/or removing the bursa and ligament is not needed to reduce sub-acromial shoulder pain and disability.
Essentially this demonstrates that arthroscopic sub-acromial decompression surgery is a placebo, and due to the costs and risks involved for this operation it strongly questions its continued use in the management of those with sub-acromial shoulder pain. There was a significant difference between the two surgical groups and the control group, demonstrating that something did have an effect on the surgical groups the question is what is that?
Physio, the new gold standard?
Well, it could be the effect of the physiotherapy and rehabilitation that was given to both surgical groups after their operations. However, before all the physios get too carried away and start to think their treatments are the new gold standard for sub-acromial shoulder pain, we need to look a little more closely at the results and put our critical thinking caps on.
First, we need to remember that statically significant doesn’t automatically mean clinically meaningful. If you look closer at the results you will see that the difference between the waiting list control group and the surgical/rehab groups is small, really small, and the authors state that they are uncertain if this difference is meaningful with the Oxford Shoulder Score they used having around a 5 point minimal clinical important difference (MCID).
We also need to remember that control groups in research trials often suffer from the phenomenon of resentful demoralisation. This is when subjects who consent to a trial realise that they are not having any treatment and start to feel hard done by. This means they often report their symptoms are worse than they actually are, possibly meaning that this control group could be even better than reported, further reducing that statistical difference!
Looking at these results we have to ask ourselves is natural history the gold standard treatment and both surgery and the physiotherapy are doing very little for a lot of cost and some risks? Does the cost, time, and resources of the surgery, or the usual 6-12 physiotherapy sessions justify the small improvements and changes in outcome seen here?
Over-treated and Over-complicated?
Now you might think I am being overly harsh and negative on physiotherapy yet again, but we have to put our practice under the same critical lens as we do with others. I am and always will be an advocate of physiotherapy and I do think we can be effective in helping those with sub-acromial shoulder pain. However, currently, I think many physios over complicate and over treat this condition doing some weird, wonderful, and wacky stuff such as scapular setting, taping, needling, and not forgetting all that shoulder symptom modification procedure business.
In my opinion, most with sub-acromial shoulder pain can and should be managed by being confidently and compassionately reassured that the pain they feel is not serious or sinister, that it will get better over time, but this will be longer than they expect or anticipate. They should be advised to carry on as best as they can and not let the pain worry them that they are harming themselves, nor should it deter them from doing activities and of course they should be encouraged to do some exercise, and try to reduce any other stressors in their lives.
It would have been interesting to see what would have happened if there was another 4th group to the CSAW trial, one that was given the information and advice that I have just mentioned as well as some general upper limb exercise. Would we have seen something like I hypothesis below? Who knows, this is just my bias and maybe for the CSAW V 2.0.
So it looks like the end is nigh for the arthroscopic shoulder decompression operation after this CSAW trial… or does it? Well, let me give you an example of one patient I had with sub-acromial shoulder pain recently and show you how sometimes it isn’t as black or white as this.
A Case Study
Last year I had a 36-year-old, very keen recreational triathlete who regularly competes in ironmans come and see me about his chronic right shoulder pain he was feeling during his swimming. He reported no previous injuries but this shoulder pain had been slowly building on and off for about a year when swimming. It was now becoming more pronounced and was limiting his ability to swim much at all, and he had also started to notice it on other activities during the day and at night when sleeping on it. He had no past medical history, he was fit and healthy, had low levels of stress, was in a job he enjoyed and had a happy family and social life.
He had already seen a specialist shoulder orthopaedic consultant privately and had an assessment and MRI. From this, he was told that he had no tears or splits of his rotator cuff and his ACJ and acromion was normal with no large spurs seen but he was recommended to have an arthroscopic decompression to give more space for his shoulder when swimming and reduce the pressure on his rotator cuff.
However, he had done some reading and knew that physio and exercise-based rehab is also an option and he was not keen for surgery. During the history taking, I could tell he was well-read on this topic, and he had hopeful yet realistic expectations of physiotherapy which we know is a strong predictor of successful outcome.
My physical assessment of him was unremarkable, he had no gross loss of movement or asymmetry, he also had no sub-acromial or ACJ pain provocation signs. The only thing I could highlight was a 25% loss of external rotation and flexion strength on handheld dynamometry testing with no major pain felt. I was unable to elicit any signs of subscapularis issues or anterior internal impingement pain on testing which is now thought to be a factor in swimmers shoulder pain. This clearly was a high performing low irritable shoulder with no major structural or biomechanical deficits that I could see.
Based on this assessment we first got him to start recording his training keeping an accurate log of his swimming volume ensuring he kept his weekly volumes between 0.75-1.5 of the previous weeks. He also started working with a swimming coach to look at his technique and had some minor adjustments but was told there was nothing major amiss here.
I also got him to look at and address any other potential stressors at home and work, and we improved his recovery strategies mainly his erratic sleeping patterns and times. And finally, of course, I strengthened the shit out of him. I got him to do two 30-45 minute sessions of S&C a week which included two upper limb exercises performed over 3-5 sets, using high load (>60%RM) moderate reps (6-12) mainly focusing on his external rotators and posterior chain, which we changed every 4-6 weeks.
At the end of 6 months he was more organised, better focused, feeling stronger than ever but… he still had the same bloody shoulder pain when swimming. After some deliberation, he decided to go ahead and have the arthroscopic shoulder decompression much to my disappointment.
He was well aware, thanks to my constant harping on about it, that this operation was not guaranteed to be successful. He was well aware that there are small but significant risks. He was aware he would be set back and would need to do all stuff we were currently doing all over again. Regardless he went ahead with the decompression.
I next saw him 3 weeks after the operation which went without any issues. The surgeons’ report was unremarkable just a standard acromioplasty with no other significant pathology noted. He had already gone back swimming a few days ago to tentatively test it out and he reported an instant improvement in his shoulder already. He knew that this could all be placebo but he didn’t care, something felt better after the operation that wasn’t before despite our best evidence-based efforts.
This case just highlights to me how despite knowing what we know, there is still a lot we don’t know. It also makes me wonder if the arthroscopic sub-acromial decompression surgery still does have a role in SOME patients who are FULLY informed of the risks and the uncertainty of what and how it works, whether this is ethical or not, well that’s another question best saved for another time.
I was going to do another blog ranting about how batshit crazy our profession can be, but instead, I thought I would try a different approach. I thought can I find any common ground with those I think are batshit crazy and who I disagree with the most.
Now don’t worry I haven’t gone soft, I just thought I would try something different other than ranting and raving and see if I can find something that may help me understand others with ‘alternative’ views and opinions. Let’s see how it goes.
So this blog was triggered after I saw a post on Facebook from someone called David Weinstock who is a Natural Therapist, whatever that is. Anyway, he runs something called ‘Neurokinetic Therapy’ and he posted on Facebook his thoughts about how tattoos and belly button piercings can affect fascia and throw your “core off” causing dysfunctions, imbalances, problems, and pain (see the post below).
Now, clearly, this a load of complete and utter bollocks and needs to be questioned and challenged, and I did, as did many others. However, this didn’t go down to well with Mr Weinstock with me being blocked and so this blog was born.
Now many tell me that I get blocked and cause disagreements because I am too harsh, too direct when I challenge stuff like this, and this is why I get resistance and kickback from people like this Weinstock character. Many say I would have more success if I ‘softened’ my approach and was more ‘polite’ and ‘respectful’.
Many think I have a short fuse and a fiery temper because I challenge stuff like this a lot robustly. But I don’t have a temper, I just have a quick and violent reaction to clear and obvious bull shit, and in my opinion, clear and obvious bullshit needs to be treated with disdain, not respect.
Usually, in my experience, those who make ridiculous claims like this will never listen to anyone who disagrees with them, no matter how nice, polite, or respectful they are. And this was proven yet again when this Weinstock character deleted ALL the questions, comments, critique, and piss-taking left on this post no matter how polite or rationale they were worded.
I see this happen all the time when anyone disagrees with those who have clear vested interests in selling a particular method, a special technique, or promoting a book or courses. When someone questions their claims they are instantly considered a threat to their business and reputation and so are often tarnished as being disrespectful for daring to ask a question no matter how its worded.
So when I see this kind of batshittery I often can’t be bothered with polite, respectful questioning anymore, there is no point, it gets you nowhere just as much as being more direct. First, you either get ignored or if they do engage, you end up going around in circles fighting logical fallacies and ad homs.
Instead, I think our efforts are better used not by trying to discuss anything with them but rather calling out this stupidity more publicly, more often
The world of crazy!
Now Weinstock and his Neurokinetic Therapy claptrap are not alone, there are many others who are just as coco-bananas, who promote their clear and obvious bull shit on social media, and who need to be called out more for it.
For example, Perry Nickelson and his ‘Stop Chasing Pain’, Ron Hruska and his ‘Postural Restoration Institute’, Tom Myers and his ‘Anatomy Trains’, Kelly Starrett and his ‘Supple Leopards and Mobility WODs’, and Naudi Aguilar and his ‘Functional Patterns’, and these clowns are just the tip of the stupid-berg…
All these individuals are notorious for making ridiculous, stupid, implausible, unsubstantiated, ‘say hello to my little friend’ crazy claims about being able to fix this, correct that, cure something faster, quicker, better than anyone else, and of course they want to sell you their books, courses, gadgets and gizmos. But more importantly, these individuals are notorious for ignoring different views and opinions, closing down disagreements and attacking anyone who dares question or challenges them or their methods.
So I thought is there ANYTHING I can find in their material and social media posts that I can work with, that I can connect with, that I can find some common ground with, that I can try to use to build a bridge to reach out and engage with them on a more positive footing.
So I dug around and looked deep into their web pages, and their online profiles, and blogs, and social media posts fighting hard to control my laughter, anger, and frustration. I looked and looked to see if there was ANY common ground…
And to put it simply, there isn’t… but, with some wishful thinking, some hard reading between the lines, and possibly clutching at some very thin straws I think I found a couple of things that we may have in common, so here they are…
No1: They want to help others (I think)?
I do think that most of these individuals have a genuine desire to help people in pain. Ok they have some bonkers, Lady Gaga ideas about how to do it, and they don’t seem to recognise other alternative explanations of why what they do does what it does, nor do they recognise the possible negative effects their methods could create. But then again, do I fully understand or recognise all the reasons why the things I do work? Probably not!
I think that there are very few malicious healthcare practitioners out there who are deliberately looking to rip vulnerable people off and don’t care about helping them. I remember seeing a video of Perry Nickelson a few months ago online where he was helping a very elderly gentleman walk after multiple strokes, and you could clearly see the joy on Perry’s face as he helped this man walk for the first time in months. Unfortunately, Perry was also promoting some stupid ass ‘Neuro Amino Frequency’ stickers/plasters that he had whacked on this gentleman’s body and head as being the reason for him being able to walk again, which clearly is complete and utter bull shit again.
In my opinion, most healthcare professionals are just not malicious people, just ignorant, misguided, and misinformed, who don’t recognise the uncertainty around what they do or realise the harmful consequences their methods or approaches have. However, I don’t feel that sorry for them as in this day and age ignorance isn’t an excuse. If these individuals chose to listen to alternative views and different opinions a little more they may start expanding their horizons and begin to realise there are other explanations.
No2: They get people moving!
They may have some screwy, squirrely, crackerjack ideas about how to do it, but most of those I disagree with do try to get people in pain to move more. Unfortunately, they do tend to focus on the small, innocuous, inconsequential details, and believe in so-called perfect posture, positioning, form for everything and anything. As much as this stupid reasoning about perfect form, or some insignificant muscle at 11% of MVIC whilst holding your breath and standing on a bosu ball makes me want to pull my face off, I think dumb movement is better than no movement.
Even the king jester of perfect alignment and correct posture Naudi ‘functional patterns’ Aguilar gets people moving a lot, and if I let you in on a little secret and you promise not to tell anyone…
*whispers very quietly* I sometimes use some of Naudi’s exercises with some of my patients!
I know its shocking, but the angry little cock womble does have some good ideas about novel movements from time to time. However, I draw the line at wrapping bands around my patient’s, giving them a gazillion instructions, and telling them this is the only way they can move.
No3: They want to make a difference!
One last thing I seem to have in common with all of these individuals is we all want to reach a big audience and spread our message, views and opinions far and wide, however, our motives are often very different.
Attracting attention in this day and age can be hard. In fact, it can be near on impossible as there is so much noise it can be difficult to get yourself heard and noticed. So at times an outrageous comment or statement can make people stop and take notice of you.
Now I am not saying this is right but I will admit I am guilty of this at times. I will often play devil’s advocate and take a much harder position than I actually have, even at times exaggerating it for effect… Except for my views about manual therapy, I haven’t exaggerated those… I hate it… that shits for real… Also, I do swear this much, that’s not for attention either!
The difference I have from those I disagree with, is I want to promote a more simple, honest, and pragmatic message that doing the simple things really well is often all that we need to do, but we need to be better at doing it. These others tend to promote the exact opposite, pushing a particular way, method, or technique that is complex and complicated and often not needed, nor backed by any evidence. I want to simplify, they want to complicate, and so this is where our common ground ends.
So there you go, some common-ish ground with those I disagree with. It was hard, really hard, actually nearly impossible, but I did it, I managed to find a couple of things I may have in common with those I don’t agree with, and actually this has made me reflect a little.
First, its made me think that I should do this more often before I go off on one, and second, that despite our differences around the unhinged, batshit crazy world of neuro amino frequency stickers, tattoos causing fascial adhesions, tight psoas muscles causing back pain, it may not matter that much if we are all just trying to help people in pain to move.
Actually, what the fuck am I on about… ignore that, bull shit ALWAYS needs to be called out as bull shit. Call it out, call out that fucking crazy bull shit… always!
I’m pleased to give you another guest blog this time from Lars Avemarie who isn’t afraid to question and challenge many things, including me, which can at times make him unpopular. As someone who is also unpopular for saying some things, Lars has done a blog on his most unpopular opinions. So without further ado, it’s over to Lars.
I hold many science-based opinions, but most of them are unpopular because they go against the old dogmatic views that are within the pain management and physiotherapy profession.
As noted by Barradell 2017 physiotherapy (like other industries) has a tendency to be tied to specific ways of seeing the world and these are passed down from old generations of physiotherapists to new physiotherapy graduates. This dogmatic way of training and teaching is one of the major reasons that is holding the physiotherapy profession back from taking a more modern and science-based view of pain management.
It is like we look at the horizon through binoculars, only focusing on a small part of it, making us blind to all the other things we could discover. We are putting our head in the sand to the last 30 years of research, for example, research that has shown us that there are many factors influencing pain and that pain is a multi-factorial experience.
The real losers in this sad situation are our clients. Because when we choose to only focus on one single point on the horizon we are choosing to be blind to all of the other possible solutions for our patient’s problem.
Here are my 20 unpopular opinions:
No 1 – Pain is modulated by emotional, mental, and sensory mechanisms, and our treatments should reflect this.
No 2 – Most health professionals lack a comprehensive scientific perspective on pain, and are often scientific illiterate.
No 3 – Often it is our education tradition and historical continuity that maintains most assumptions about what we do and learn, it is not the repeated assessment of the validity of these assumptions (adapted from Edward DeBono)
No 4 – The ‘toolbox’ approach to pain management does not provide optimal treatment and typically its results rely on non-plausible and non-scientific therapeutic modalities.
No 5 – A barrier to a more scientific approach to pain management is the old dogmatic way of viewing the body that is still being taught to health professionals, these ways are passed down to new generations from the past generations.
No 6 – Pain is a multidimensional experience produced by multiple influences, and our treatments should reflect this.
No 7 – Pain management is suboptimal when done with a purely biomedical ideology.
No 8 – Pain (both acute or chronic) is always a biopsychosocial experience and will, therefore, be influenced by patient’s goals, beliefs, experiences and predictions, our treatments should reflect this (thanks, Dr Bronnie Lennox Thompson for that one).
No 9 – Pain felt in the body is not a “thing” but many therapeutic modalities have conceptualised pain as something in the body like a kidney or a patella. Pain is not a somatic entity. This erroneous belief leads the therapist to try and attack this “thing” called pain forgetting that it is an experience.
This is like going to Norway and viewing aurora borealis (an experience) to staying at home trying to find aurora in your own knee. (Thanks to Dr John Quintner for that one).
No 10 – Health professionals talk a lot about the quality of care and making healthcare better for the future. However, you don’t increase quality by saying “yes” all the time and being overly positive towards every type of treatment, part of getting higher quality care is by saying NO to low-quality treatments.
No 11 – It is often assumed that an error in a movement will cause an injury, tissue damage and/or pain. But most health professionals forget the specificity principle, and that an adaptation could also be a result of this.
No 12 – A problem in pain management right now, is that there is an epidemic of bad reasoning. This is a pandemic of “broscience” and non-scientific thinking and dysrationalia. In debates, when people are faced with an argument and/or evidence that goes against their belief, the common answer is “but I know it works”, or “I have seen it work”.
No 13 – Structure and biomechanics are not destiny, most findings on imaging are also common in asymptomatic individuals.
No 14 – Finding “errors” in people like bad posture, tilted pelvises, weak cores, sacroiliac joints “out”, “tight” muscles, imbalances, faulty movement patterns or any other bio-“mechanical” problems are not single causal factors for pain, and are also common in people without pain.
No 15 – Human movement and the human body exhibit unique individual characteristics much like fingerprints. Finding “errors” in gait, running, and movement is problematic due to the high variability. This puts a big hole in the theory about assessment, it is very difficult to know what is a “dysfunction” (hate that word) or a normal variation.
No 16 – Personal anecdotes and “clinical experience” are unreliable and therefore we cannot make any reliable and sound assumptions based upon them.
No 17 – I’ve seen it “work” is not an argument a health professional that provides care for another human being should make, we have to do better, “With great power comes great responsibility.”
No 18 – The placebo effect does not justify “magical” pseudo-scientific non-plausible treatments with only dubious evidence.
No 19 – Most advice on ergonomic sitting (and to some degree lifting) is based on old data, and makes the faulty assumption that “stress” leads to injury or pain. This assumption goes against the S.A.I.D principle. People will adapt to increased load like a deadlift, but then to say this does not apply to sitting with their head a little bit forward is just not logical.
No 20 – Psychological factors like depression, fear-avoidance or pain-related fear are often more important to the influence and development of chronic pain than most biomechanical or biomedical factors.
Thanks to Brian Rutledge for the idea of this post.
About Lars Lars Avemarie is a personal trainer and 3rd-year physiotherapy student. Lars has a unique blend of knowledge about pain science, neuroscience, physiotherapy, evidence-based practice, exercise science, rehabilitation, sleep research and critical thinking. He has worked almost a decade full-time in the healthcare industry. He has specialised in the training of clients with injuries and chronic pain.
I often see blogs and images that promote the traits, virtues, and qualities of good physiotherapists. They often say things like good physios are kind, empathetic, caring rays of sunshine, that give hope when all is lost. Although I understand the point and sentiment of these posts they are simply not realistic.
Having been a physio now well over 20 years, I have met all kinds of physios with all kinds of skill, knowledge, and enthusiam. From the disinterested dinosaur coasting along doing the bare minimum possible to get through the day not giving a fuck about anything or anyone. To the motivated, ambitious, energetic bunny who wants to help anyone and everyone to the best of their ability.
So I thought I would take a more honest and ‘realistic’ look of what I think are the traits of a good physiotherapist that is beyond the sickly sweet obvious stuff. So buckle up and hold tight, and get ready for a big old serving of some brutal honest reality!
No1: Good physios can deal with a lot of silly bullshit
With the rise of Google-insta face-tweet book, lots of patients go to see physios with their heads stuffed full of pseudoscience, nonsense and silly bullshit thanks to some pea brain, ignorant, social media guru with a bazzillion followers. Often the good physios sit quietly and calmly while screaming on the inside as they listen to patients telling them some ridiculous far-fetched non-scientific bollocks that they saw or heard a guru say on the internet.
Shit physios dont care about this and will just ignore it or even agree with the silly shit. Good physios however carefully, tactfully, and compassionately try to unpick this bull-crap from the minds of their patients, trying to explain things in a more simple, rational, honest and evidence-based way, often only to be told that they clearly don’t know what they are on about because Dr ‘Social Media Guru’ DPT, CSCS, OMT with his bazillion followers says differently.
No 2: Good physios can change peoples minds
Even harder than trying to compete with an idiot online is trying to manage the shitty advice patients get from their friends, family, or even their trusted local healthcare professional. Patients often come to see physios with low or unrealistic expectations due to some misinformation gained from their family doctor or local surgeon.
For example, many patients are told that physio will be a quick, simple, easy process and they will be better in a few weeks when they’ve had a complex painful chronic condition for years. Or conversley they are told the opposite, that physio won’t help them for something it can quite easily help with!
Again shit physios dont care, but the good ones will spend extra time and energy trying to manage these ill-informed unrealistic expectations which is often a difficult, time consuming, and thankless task.
No3: Good physios dont do it for the money
There are huge differences in the wages of all healthcare professionals, with some being paid very handsomely for what they do due to their extended skills, experience, training, and the risks of what they do. However, when you look at the average earnings of a good, experienced, well-qualified physiotherapist compared to other healthcare professions they are paid poorly, very poorly.
There are now many physios working in extended roles and positions of great responsbility and risk who get paid a fraction of what other professions working in the same roles do. Don’t get me wrong, the lazy disinterested dinosaur physios who are coasting along doing the bare minimum possible I think are getting overpaid for what they do. But the hard-working, evidence-based physios simply do not get paid enough for the level of time, experience, and responsibility they have.
No4: Good physios work hard
Some physios works up to 12 hours a day for 5-6 days a week, seeing patients back to back giving each one their full attention, care, and compassion with little to no time to catch up on paperwork, emails, or even eat. Good physios also use what little precious spare time they have to seek more knowledge and advance their skills further by reading books, papers, and attending post graduate courses at the weekends.
Unfortunately most physio employers do not give their physios any financial support, time, or even incentive or encouragement to do these things. Instead due to the increasing demand and growing pressures on servies, most physio employers want physios to see patients and do very little else.
No5: Good physios work really hard
With waiting lists increasing and all healthcare services under more and more pressure, appointment times are getting shorter and shorter and the working days are getting longer and longer. Many physios can see more than 20 patients a day which is not only mentally and phyiscally exhausting, it makes it increasingly difficult to give good quality individualised care and treatment let alone build a therapeutic alliance with patients.
However, the good physios do attempt to give each and every patient they see their full attention and best efforts, listening attentively and tailoring their approaches to suit the perosn in front of them. This often means they work harder and longer than others again without any recognition or rewards.
No6: Good physios practice what they preach
Good physios really understand the importance of maintaining a healthy, physically active lifestyle and the vital role it plays in keeping both a healthy body and mind. Good physios lead by example by doing regular exercise despite the pressures on their time and resources.
Often good physios find themselves listening to others explain how they can’t find the time to fit in a few minutes of physical activity, even though they have worked 12 hours and only had 30 minutes for a pee and some food and still go for a run or do those deadlifts at the end of a clinic.
No7: Good physios are lifelong learners
Many shit physios havent picked up a journal since they graduated and couldn’t care less about the changes in research or practice. However, the good physios have committed themselves to a lifelong process of continuous learning. They realise that knowledge is forever changing and shifting and what they know today will be different or even obsolete tomorrow.
The good physios look to challenge their understanding and knowledge from many areas and sources, recognising that there are many explanations of what they do and why it works. Good physios are comfortable and confident with their uncertainty and are able to pass this on to their patients and others around them.
No8: Good physios make a difference
Despite all the pressures and limitations on their time and resources, good physios try to make a difference in all they see. Even if its as small as getting someone to move a little more each day, or by reducing their fear of a certain task or activity a little bit.
Sometimes this difference can be just getting a patient to think differently about a problem or an issue.
Good physios also don’t exaggerate their results or feel the need to promote their success to everyone and anyone on social media with stupid before and after pictures. Good physios understand that successful results are often not quick or easy and change is a difficult slow and gradual process.
Good physios recognise those who continually shout about and promote their few quick fixes and successes often forget about or ignore their many failures.
No9: Good physios challenge stupid bullshit
Physio is often stereotyped by patients and other professionals as just some massage and silly exercises. Good physios know different and they question and challenge the many dubious claims and dodgy interventions they see being used in their profession.
Although challenging bullshit is often perceived by many as being unprofessional or harmful, good physio recognise that pseudoscience, misinformation, and silly shit is far more unprofessional and harmful.
No10: Good physios have a laugh
Despite all the challenges and difficulties that exist to providing good quality evidence-based physiotherapy, good physios do the best they can as often as they can with a smile on their face. Good physios recognise that although it can be incredibly difficult and stressful for them to do a good job, they know that they have to put their patients first.
Good physios also recognise that some banter and humour is essential in this oh so serious and oh so uptight world of physiotherapy with its many prudes and pearl clutchers in positions of authroity
So there you go, thats what I think makes a good physio beyond being nice, caring, kind and all that other condesceding crap.
I understand that sometimes it’s hard to stay on the path of a good physio and it would be much easier and often far more financially rewarding to take another path. I also know it’s very tempting to get dragged into the world of social media algorythum and gurus, posting sexy-looking, complex, yet ineffective treatments, and other silly bullshit for likes and follows.
But please recognise that being a good physio is far far more than being popular on social media and that good physios will always remain true to themselves and their principles.
So thank you to all the good physios out there, you rock.
Special orthopaedic tests are used by clinicians in the assessment of those with suspected MSK pain or injury. There are a mind-boggling number of these tests, covering all areas of the body usually named after the surgeon who invented it. They are believed to diagnose MSK structures that maybe damaged or sensitive. However, it’s time to look at these ‘special’ tests differently and start to realise that perhaps many ‘special’ tests are not that ‘special’.
There is no doubting that a full, detailed, and thorough physical exam is essential when assessing someone with pain or injury, and sometimes using special orthopaedic tests are part of this. However, these special tests are often relied upon too easily, too readily, and trusted too implicitly to confirm a diagnosis when they often can not and do not.
The shoulder arguably has more special tests than any other area, and they are believed too ‘diagnose’ all manner of pathologies. At my last count, there were well over 200 tests for shoulder pain and this continues to grow as more and more are dreamt up. However, despite common assumption and still being widely taught, many special tests don’t and can’t do what they claim they can do.
For example, the belief that the ’empty can’ special test stresses the Supraspinatus tendon more than the ‘full can’ special test is not actually true, in fact, both can positions do not stress ANY part of the rotator cuff more than any of the other surrounding shoulder muscles (see figure below ref). Also, the belief that pain on the ‘Speeds’ or ‘Yergasons’ special tests isolates the long head of biceps from the other surrounding shoulder tissues and therefore is more specific for biceps tendon pathology is also not true (ref).
And this is not unique to shoulder special tests, it is also the same for many other special tests in many other areas. For example, the belief that pain during the ‘McMurrays’ special test stresses and strains the knee meniscus alone is not so (ref). The belief that pain on the ‘Spurlings’ special test or during the ‘upper limb tension’ special tests only indicates neural compression or tension is just not so (ref)… etc etc ad infinitum.
Special tests simply do not isolate specific tissues or structures, therefore when pain is reproduced during these tests all they tell you is that pain is reproduced not what the source is. That’s even if there is mechanical ‘source’ for the pain at all.
Sometimes I think pain can be reproduced during these tests simply due to expectations of it going to hurt, especially when I hear a clinician explain to the patient what the purpose of this special test is for eg… “Ok Mrs Miggins I need to assess your Rotator Cuff now, this may hurt a little bit when I do this…” talk about priming painful expectations!
However, this is not to say that all special tests are completely useless, for example I do not know a clinician who would not do a Lachmans after a suspected ACL rupture or Hoffmans or Babinski tests for suspected cervical mylopathy, we just have to recognise their limitations, and stop calling them special.
Personally I think they should be called pain provocation tests, and although most pain provocation tests are not very special or specific, that is they can not rule in a particular tissue, structure, or pathology, they tend to be more sensitive, that is they are better at ruling out a tissue, structure, or pathology. I think negative pain provocation testing is far more useful than positive pain provocation.
I often like to tell the patient what its not even when I can be certain about what it is!
It must also be remembered that the physical exam is always shaped and influenced by the patient’s history. For example, someone with knee pain who tells you they heard a loud pop and sudden pain after turning and twisting suddenly, is going to have a different exam than someone who tells you of knee pain building gradually when they walk more. You are probably only going to do a Lachmans ACL laxity test on one of these patients. The history always shapes your exam. You will NOT do all the same tests on all the patients you see.
However, there is an exception to this rule, there is actually one ‘special’ test I do with every patient I see during every physical exam regardless of where their problem is, or what I suspect the pathology is or is not. This is the ‘most special orthopaedic test’ and it is one I think every clinician should do.
I ask every patient what is THE most painful, fearful, difficult thing for them to do. Once they tell me what this is, my ‘most special orthopaedic test’ is to get them to do the one thing they just told me they don’t want to do.
This may seem unconventional, harsh, mean, unkind or even uncaring, however, I find it is really useful to observe a patients response and wiliness to do the one thing they don’t want to do. It allows me to gauge their function, pain, fear, anxiety, apprehension etc all in one simple quick test before I go on to look at other things.
It truly is the most special of all the special tests. Give it a try.
We have a responsibility to our patients to prove that our treatments are both safe and effective. However, trying to prove that a treatment is ‘effective’ is both complex and challenging and there are many ways very smart intelligent people are often fooled into thinking a treatment has worked when actually it hasn’t.
One of my personal heroes Richard Feynman once said: “no one can fool you as easily as you can fool yourself”. So it is essential for all healthcare professionals to be aware of other alternative explanations of why treatments appear to work!
There are many reasons why clinicians and patients alike think ineffective treatments work, I am just going to discuss the 10 most common ones in an effort to ensure you are not fooling yourself.
No1: Correlation ≠ Causation
Humans have a tendency to assume that when things occur together they are connected. For example, there is a correlation between drinking coffee and cancer, and so many conclude that drinking coffee gives you a higher risk of developing cancer. But there are many other reasons why this coffee and cancer correlation exists, the most obvious one being that a lot of people who drink coffee also smoke?
When giving treatments for anything many factors are occurring simultaneously making it extremely difficult to determine what is a cause and what is an effect. Without comparing a similar group of people treated identically except for the believed effective treatment being withheld and an inert sham treatment is given instead, we can never know whether they would have recovered just as well without it.
No2: Natural History
Many health conditions are self-limiting. Natural history is medicines, surgery’s and physiotherapy’s dirty little-unspoken secret. Providing a condition is not fatal, the body’s own self-regulating, self-healing processes often restore it back to homeostasis and the sufferer back to health.
Thus, before a treatment can be acknowledged as effective, its advocates must demonstrate that the number of patients listed as improved exceeds the number expected to recover without any treatment, or that they have recovered significantly faster than if left untreated
No3: Cyclical Conditions
Multiple sclerosis, gastrointestinal complaints, arthritis, tendinopathy and many other conditions are examples of diagnoses that have natural ups and downs in their symptoms. Naturally, sufferers tend to seek treatment when symptoms are at their worst and many treatments have repeated opportunities to coincide with natural remissions and downturns giving an illusion of effectiveness.
In the absence of appropriate control groups, patients and clinicians are prone to misinterpret improvements seen due to normal cyclical variations as a treatment being effective.
No4: Spontaneous Remission
Even with serious terminal diseases such as cancer, spontaneous remissions can occur. The exact mechanisms responsible for these are not well understood, but the immune system and psychological variables no doubt play a large role.
Thoughts, emotions, desires, beliefs, etc, are physical states of the brain, and these neural processes affect glandular, immune, and other cellular processes throughout the body that will, in turn, affect healing processes.
Psychological variables have widespread physiological effects that can have positive or negative impacts on health. While some research has confirmed such effects exist, it must be remembered that they only account for a few percentages of a diseases variance.
However, many alternative treatments and therapies have received unearned acclaim for spontaneous remissions because many desperate patients turn to them when they feel that they have nothing left to lose. When there is a positive response the treatment advocates assert that they have snatched the hopeless individual from death’s door, but rarely do these “miracle workers” reveal what percentage of their clientele these successful cases represent.
No5: Placebo Effect
Another reason why treatments are incorrectly credited with improvements is the ubiquitous placebo effect that I have discussed many times before.
Through a combination of suggestion, belief, expectancy, and diversion of attention, patients who are given biologically inert treatments can experience measurable relief. Some placebo responses produce actual changes in physical conditions; others create subjective changes that make patients feel better.
It is therefore essential that randomised placebo-controlled trials are conducted on all treatments, but because of the power of expectancy and compliance effects are so strong, clinicians and patients must be blinded which unfortunately is often not done well. Blinding is essential in research because of barely perceptible cues can unintentionally convey bias that can and do affect treatment results.
No 6: Interaction NOT Intervention
A constant difficulty in trying to measure a treatment’s effectiveness is that many physical complaints arise from psychological distress and can be alleviated by support and reassurance alone. Many clinicians cater to the “worried well” who are mistakenly convinced that they are ill, often expressing psychological concerns as physiological symptoms.
With the aid of pseudoscientific diagnostic devices, some practitioners will reinforce the conviction of these ‘worried well’ that the standard, cold-hearted, narrow-minded medical establishment, which can find nothing wrong or amiss, is both incompetent and unfair in refusing to acknowledge their very real condition.
Through the ritual of ‘delivering treatment’ these therapists supply the reassurance and support their worried clients seek, and there is no doubt this can be helpful and worthwhile.
However, the downside to this is that catering to the desire for medical diagnosis of psychological complaints promotes pseudo-scientific thinking which inflates the success rates of charlatans and quacks.
Saddest of all, however, is it continues to perpetuate the myth that there is something shameful or illegitimate about diagnosing patients physical pains and disabilities as manifestations of their psychological problems such as anxiety or hypervigilance.
No7: Symptom Relief ≠ Treatment
There is no doubt that alleviating pain and discomfort is what patients value a lot, but many treatments make symptoms more bearable without actually “treating” the underlying condition.
Pain is a multifactorial sensation and by successfully reducing the emotional component it can leave the sensory portion surprisingly tolerable. Thus, the suffering of pain can often be reduced, even if the underlying pathology is untouched.
Anything that can allay anxiety, redirect attention, reduce arousal, foster a sense of control, or lead to the cognitive reinterpretation of symptoms can alleviate pain. When patients suffer less, this is good, however, we must be careful that we are not constantly removing pain unnecessarily or diverting time or attention away from proven active treatments for their underlying conditions.
In this era of modern medicine and the obsession with perfect health and fitness, many people are induced into thinking they have conditions they do not have.
When these “healthy folk” receive what should be good and reassuring news from rational, evidence-based clinicians that they have nothing to worry about, they often reject this and gravitate to “alternative practitioners” who can and almost always do find some kind of problem, imbalance, misalignment, or issue with a tissue.
When recovery of their non-issues follow another convert to the weird and wacky world of pseudo treatments is born adding strength to the quacks reputation and dubious interventions.
No9: Derivative Benefits
Many “alternative practitioners” have charming, charismatic personalities, and very strong ‘bedside manners’. If an enthusiastic, upbeat practitioner manages to elevate a patient’s mood and expectations, this can lead to greater compliance with, and effectiveness of, the orthodox treatments he or she may also be receiving.
This expectant attitude can also motivate people to eat and sleep better, exercise and socialise more. These things, by themselves, could help improve the natural recovery which is far from being a bad thing, unless it diverts the patient away from more effective treatments, or if the charges and costs are exorbitant.
No10: The Will to Believe
Even when they derive no objective improvements, devotees who have a strong emotional and psychological investment in alternative treatments can convince themselves they have been helped.
Cognitive dissonance often occurs when experiences contradict existing attitudes, feelings, or knowledge. So we tend to alleviate this uncomfortable feeling by reinterpreting the offending information.
For example, rather than admitting to ourselves or to others that we have received no relief after committing time, money, and “face” to a treatment, many will find and inflate some redeeming value in the treatment rather than admit it did nothing.
Clinicians and patients are often prone to misinterpret and remember things happing as they wish had happened. Similarly, they may be selective in what they recall, overestimating the apparent success while ignoring, downplaying, or explaining away the failures.
Finally, there exists the phenomenon of the “norm of reciprocity” which unless you are a complete arsehole is an implicit rule that obliges people to respond in kind when someone does them a good turn.
Many clinicians genuinely try to help patients so its only natural that patients want to please them by saying they feel better. Without realising it, these obligations are sufficient to grossly inflate our perceptions of how effective our treatments are.
As you can see there are a host of ways treatments can appear to work. For patients who are unwell, disabled, and in pain, the promise of a cure, a fix, or some help is appealing and beguiling. As a result, false hope can easily supplant common sense, and desperate patients can and do make clinicians do desperate things.
I will leave you with the late, great, Godfather of evidence-based healthcare Archie Cochrane’s famous quote which I think is fitting here…
“Altering the natural course of any clinical condition is a difficult and complex challenge and one should be delightfully surprised when any treatment is seen to do this, but one should always assume that any treatment is ineffective unless there is strong, robust, reproducable evidence to the contrary”
No one likes to think what they do is worthless. No one likes to think that their role is meaningless. But this could be what many musculoskeletal physiotherapists, are facing if our interventions are found to be nothing more than placebo.
The placebo effect is defined as a beneficial effect that can NOT be attributed to the treatment but rather to a patient’s expectations or other unknown effects. This should not be confused with natural history or contextual effects.
Contextual effects are described as the influence of environmental and/or psychological factors on patients perception of treatments. This can be things like rapport, empathy etc. Natural history is the usual course of a disease or condition in the absence of treatment.
There is no doubt that the placebo effect is present in all healthcare interventions, but just how much is something we don’t know despite many often quoting Beechers infamous 1955 study that suggested it was 30%. The placebo effect is getting more and more attention recently with many asking how much it affects our physiotherapy treatments?
To answer this we need placebo-controlled research and studies. Unfortunately, these are rare in physiotherapy with the argument often being that it’s hard to find convincing placebos for physiotherapy treatments. Another argument is that we can’t study the effects of our physio interventions within the sterile confines of placebo-controlled trials because we are dealing with complex issues such as humans and pain.
However, these arguments stand on very weak ground. Surgery and medicine also deal with complex issues and people in pain, yet they do placebo-controlled trials far more than physiotherapy. Physios are often quick to highlight how surgery or medication is no more effective than placebo, yet are less keen to turn this critical lens onto their own interventions.
When placebo-controlled studies are occasionally done within physiotherapy we see that a lot of what we do doesn’t appear to create any significant benefits over or above shams or placebos. A recent study that highlighted this was a trial here looking at McKenzie based exercises for low back pain versus a detuned sham ultrasound machine.
This trial demonstrated that McKenzie exercises had only a slight, and I mean very slight, benefit on pain after 5 weeks of treatment, but no difference in pain or disability at 3, 6, or 12 months when compared to sham electrotherapy. Yep, that’s right, using a machine that wasn’t even plugged in works just as well as one of our most popular movement-based interventions for low back pain.
Although this is a small trial these results should make all physios feel uncomfortable, I know it does for me. Surely we would expect a popular and often used intervention that encourages movement and self-management to have shown more effect than a bloody decommissioned ultrasound machine!
There are other papers that also highlight how many other physiotherapy interventions, mainly the passive ones for back, hip, knee, shoulder pain also do nothing more than doing nothing or sham interventions. So as the famous French philosopher Voltaire once said, is physiotherapy “amusing the patient whilst nature cures the disease”?
Doubts And Frustrations
I have had doubts for years that most of what I do as a physiotherapist is nothing more than a placebo despite my best efforts. This is often reinforced when I read papers like the one above but also when in my clinic and I see patients get better despite clearly having done nothing I suggested.
However, I also see patients who don’t get better despite doing everything I ask of them and following all of the advice I give. Why is this? Why despite my best efforts and following all that the best current evidence tell me do some patients get better regardless and yet others don’t?
Well, I don’t know is the simple yet frustrating answer. There is no doubt its due to things just getting better on their own, but it is also due to many of the interventions we give don’t work the way we have been taught or believe they do.
It is also due to our interactions often being more important than our interventions in getting results, with the act of treatment being more important than the treatment itself. Finally, I’m also sure it’s due to the ability of anyone to get better or not ultimately lies within an individual’s beliefs and attitudes, not treatments or interventions.
A discussion I often hear within physiotherapy is that we need to understand and utilise the placebo effect more as a treatment. Many think that we shouldn’t even call it the placebo effect any more due to the negative stigma around it, rather we should just call it a ‘non-specific’ effect.
Regardless of what you want to call it, we should NEVER be happy o satisfied to treat people with placebos or non-specific effects, and we should NEVER confuse the placebo effect with other non-specific or contextual effects or the host of other weird things that can occur when we treat people, more on that here.
These discussions about using placebos knowingly and actively in physiotherapy make me want to smash my face up against a hard surface repeatedly. First, because I find it frustrating as hell that some physios have a genuine belief that they can unlock the mysteries of the placebo effect that many much cleverer people have been unable to for decades ever since Beecher’s first attempt.
The other reason these discussions around the placebo effect frustrate me is that some physios think it’s a powerful untapped potential miracle treatment. It simply isn’t, the placebo effect is actually kind of weak and pathetic and we should never be happy to rely on it to help people.
Despite Beecher’s first attempt to quantify the placebo effect, famously quoting it as being ‘powerful’, it’s actually weak, short-lasting, and really, really unreliable. The strongest non-specific effect that tends to occur is natural history, not placebo as many think.
Therefore why do we want to waste our time, efforts, and resources on investigating something that ultimately we will never fully control and even if we do it will have questionable small to minimal impact on outcomes.
More Than a Placebo
Now before I make all of you reading this feel worthless as a sugar pill and surplus to requirements, there is no doubt that some of our physio interventions are clearly more beneficial than placebo. Exercise being the main one. However, just not for the treatment of pain, only for improvements in health and well being
There are a few placebo-controlled studies on the effects of exercise in those with pain and pathology and again as with the McKenzie study they do not always show significant benefits over placebo (ref, ref, ref)
The how and why our exercise interventions help is still not fully understood, and it may be more about the process of exercising rather than the outcome that’s important (ref). It may also be the volume and frequency rather than the type of exercise that is key (ref).
Regardless, of these uncertainties, I think our roles as physiotherapists in supporting, encouraging, educating, reassuring, motivating, confronting, challenging, and cajoling people in pain and disability to move more is more beneficial than placebo. But remember, I’m biased, hugely.
Let me make it crystal clear that I am not looking to beat down on the physio profession when I question if it’s just a placebo. Believe it or not, I will always be one of physiotherapy’s strongest advocates. I truly believe that physiotherapy can and does have an important role within modern healthcare, but only if it gets its head out of its arse and evolves.
Evolve Or Die
Just as I am one of physios strongest advocates, I am also one of its strongest critics. Many think that I harm our profession by questioning and challenging it so much so publicly. Some think this will be the end of us, and there are a few snowflakes who think all this is just too mean and nasty!
These individuals I think need to tolerate disagreements and differences better and recognise that if we don’t question and challenge what we do we will fail to progress and grow.
I am glad that more and more in the profession have started to ask some tough and awkward questions. I am happy that the things that have often been overlooked and avoided scrutiny and critique are now being dragged into the light kicking and screaming and being shown to be nothing more than placebos.
And if it takes a few feelings to be hurt, a few feathers ruffled and a few dinosaurs fossilised, or even the death of the profession as we know it, then so be it! I would rather burn down my own rotten house to the ground, and start afresh building a new more robust one.
More physios need to learn to accept that most, if not all of our shitty passive treatments and adjuncts such as massage, manipulations, electotherapy machines, tapes, needles, etc are most likely nothing more than placebo.
As I have said it before, if physiotherapy as a profession wants to be a valued part of modern evidence-based healthcare then we have to distance ourselves away from the low-value interventions, including placebos.
If we continue to defend these dubious and unreliable treatments then I fear our profession stands the very real risk of being cast to the fringes of healthcare and the world of ‘alternative medicine’ with all the other quacks and nut jobs with their energy crystals and chakras.
And I have no desire to be an ‘alternative’ health care provider.
Good, I’ve got your attention!!! Well now you’re here let me tell you why I think therapists are soft and it’s not for the reasons you are probably thinking.
I think many therapists are ‘soft’ as they are often more afraid, scared, and fearful of pain in their patients than the patients are themselves. As a consequence, I think this fear many therapists have around pain is, directly and indirectly, transferred onto those they see.
One of the biggest contradictions I see with many therapists is how they often say they assess people in pain checking for signs and symptoms of serious and sinister stuff, but often recognise how most musculoskeletal pains are not serious or dangerous and poorly correlated with tissue status or pathology, and how pain doesn’t equal damage, hurt doesn’t mean harm, and sore can be safe, but then act and behave completely differently.
Despite many therapists saying pain is safe and normal many still tell their patients to avoid it and stop doing tasks or activities that cause it. Also, despite many therapists saying pain is often nothing to be alarmed or concerned about many still look to reduce and remove patient’s pain with their ‘symptom modification’ tricks, manual therapy techniques, neon coloured tapes, silly little needles, or laser machines that go pew-pew!
Therapists and Pain
Why so many therapists say one thing about pain and then act completely different is both confusing and perplexing! Especially when I see so many of them telling people in pain to stop tasks or exercises that hurt, but quite happily press, push, poke, or scrape them with their manual therapy treatments causing them immense pain and discomfort!
Again, why so many therapists think that pain during manual therapy treatments is ok, but pain during exercise or other meaningful active tasks is not ok is just confusing to me?
I think this mostly comes down to how therapists are trained and their inherent desire and empathy to want to help those they see in pain. Most therapists do this job because they want to help others in pain, and often it is thought and taught that the best way to do this is by rubbing, poking, and pressing painful things in patients and asking them to avoid tasks and exercises that cause pain.
However, I don’t think this is right or correct advice for many in pain and I think if the therapy professions want to play any role in reducing the chronic pain epidemic that our species has got itself into, we need to understand and recognise that avoidance of tasks and movements that hurt and the quick fixes and treatments we often use to reduce or remove pain is not always the best solution.
However, I do recognise this is challenging, alien, and almost unthinkable for many therapists due to their training and instincts that often means they would not consider asking someone in pain to do something that hurts or makes their pain feel worse, even for a short period. Some therapists even think it’s immoral and even unethical to let pain continue or go untreated, breaking one of the fundamental rules of healthcare… “do no harm’.
Do No Harm ≠ Do Not Hurt
Trying to convince therapists and other healthcare professionals that pain doesn’t always need to be reduced or removed is hard. But it’s even harder to convince those who are experiencing it. Pain is unpleasant, at times downright awful, it demands attention, it makes you think the worst, it changes your behaviour, and no one wants it. But we have to start thinking about pain differently.
Pain is a fundamental part of being human and as much as we think it would be nice to live without it, it would actually be horrible. At first, you may think living without pain it would be an advantage, allowing you to go through life easily, tolerating things others couldn’t like a superhero.
However, a life without pain is a terrible affliction and an awful curse. A rare genetic condition called congenital insensitivity to pain does cause a few people to never experience pain, but unfortunately, these individuals often have short life spans and live in constant fear of a serious injury or illness that goes undetected until it’s too late.
For example, just imagine what would happen if you didn’t get any pain when you bite your tongue whilst eating? You would carry on chewing with a bit of extra tongue blissfully unaware. What about when you lean on a hot cooker, or cut yourself, or get an infection or some other disease and not know about it until you see your flesh melting, bones sticking out, puss oozing from a wound, or pass out from a fever you couldn’t feel?
Simply put, pain is a much-needed part of our existence that protects us and keeps us safe. To go through life without pain is neither safe nor practical, yet this is exactly what’s happening more and more to our society.
Our easy convenient lives mean we rarely have to do things today that are hard, difficult, challenging, or painful. As a consequence, we are not experiencing effort, hardship, or pain as often or as regularly as we used to. And even when we do experience pain we don’t endure or tolerate it for as long as we used to. Again you may think this is good, I don’t!
We all live lives so comfortable and so pain-free that I think it is causing many of us to become less and less tolerant of pain and just as with those with ‘congenital insensitivity to pain’ I think it is putting us in danger.
We have over generations gradually lowered our tolerance to pain, and as a consequence we feel it sooner and easier than ever before with lower and lower stimuli. The human race is becoming more hypersensitive, more intolerant, and more vulnerable to pain, and this is in part, the fault of our modern lifestyles, technology, but also healthcare.
Now don’t get me wrong, I love my central heating, warm showers, wifi connection, home deliveries, and soft comfy mattress, and I am not advocating we all suddenly devolve back to cavemen, sleep in caves and live lifes of hardship and strife. But when you’re intolerant to something one of the most effective ways to become more tolerant to it is through exposure to it, and that’s what I think is need with pain!
Now again don’t get me wrong, I don’t think we all need to start going out there and deliberately start inflicting pain upon ourselves or others, rather that when we do experience some pain that isn’t serious, sinister, or harmful that instead of immediately reducing or removing it, we endure and tolerate it a bit more!
I was taught as a physio to always try and reduce pain in all of my patients, and I used to try my hardest to do this. But I wasn’t always successful. This used to frustrate and dishearten me, making me feel like a failure, and I thought about quitting this job many times. However, I began to realise and learn that it doesn’t have to be this way.
As I learnt more about pain, and started to understand it better and recognised that it didn’t need to be reduced or removed immediately, I started asking patients in pain to carry on and persist despite their pain, reassuring them it wasn’t dangerous or detrimental but normal and natural. And many improved and got better.
These days I tend to advise more and more patients after a full and thorough assessment to continue on as they are despite their pain and not to worry too much about things that hurt or cause discomfort, rather than always ask them to avoid it or me trying to reduce it. And despite this sounding harsh, uncaring, and discompassionate… it’s not at all and in fact, it’s actually rewarding and more importantly effective.
Asking patients to carry on, or start doing things that hurt tends to be a bit of shock and surprise for many of them, and I find it often challenges and confronts their beliefs and expectations of what they thought physiotherapy was. But with clear, concise, and compassionate explanation and reassurance, many do understand, but I’m not going to bullshit you and say all do, as they don’t.
Some patients really don’t care, like, or believe me when when I say that the pain they feel during a movement, task, or exercise is safe, ok, or even beneficial. Some just want it reduced or removed. This often happens because I haven’t done a good job in communicating or connecting with them to be trusted or believed and we have to recognise this happens because… humans are complex!
However, what I have learnt over the years of using exposure to pain is that to get patients to do things that hurt you can NOT be a cold, dis-compassionate, hard-nosed military drill sergeant barking orders at them. Rather you have to be a calm, collected, confident guide who gives them the confidence and reassurance that they can do this despite their pain
I see a lot of people these days who have been told to rest, reduce, remove, or avoid pain for weeks, months, even years and it hasn’t helped them, in fact, it has often made them worse. I now find myself reversing this by reassuring, motivating, and encouraging them to try things that hurt and start to get things going again.
But there is no doubt that getting patients to do things that hurt is difficult, really difficult and many are reluctant and some refuse. The key I find is to develop a good relationship and rapport early on and don’t promise things you can’t keep, like saying “don’t worry it won’t be as bad as you think” as usually, it is as bad as they think to begin with.
Another key point I find with this exposure to pain method is that repetition is essential, and not to let them do a painful task or exercise just once, but many many times. In my opinion repetition is essential for reinforcement and can produce confidence that they can expose themselves to more and more things that hurt and are in control of their own pain.
What painful tasks or exercises I get patients to do varies hugely based on what they tell me, but it’s often the things they have told me they can’t do or hurts them the most. Sometimes it’s getting them to pick something off the floor, sometimes it’s getting them to reach up high, sometimes it just stepping down a step.
What’s The Evidence?
There is some growing evidence that exercises and tasks that are painful may have some significant advantages over and above non-painful exercises in those with chronic pain who have avoided these tasks and activities for an extended period. A recent systematic review published in the British Journal of Sports Medicine here has shown exercises that cause pain up to around 5 out of 10 on a pain scale can have beneficial effects for many chronic musculoskeletal conditions with no harmful or detrimental effects.
Source: BJSM, Smith et al (2017)
However, as with most things getting some to do painful exercises or tasks may not be best, and some caution is warranted in some populations. Repeated exposure to painful stimuli can be great in developing confidence, tolerance and habituation to pain, but it can also create increased sensitisation to it in some (ref, ref, ref). It appears that some populations and conditions do not get the same pain inhibiting central responses with painful exercises and so we do need to recognise this.
Also, I don’t think we always have to ask chronic pain patients to do exercises or tasks that hurt. For example, if there is a way to continue to do a task or exercise without much pain then thats ok at times do. Sometimes creating a simple change in position, speed, or load can reduce pain in a task, however, I do think you should always revisit the original painful movement or task at some point and see if you can also develop resilience to it through exposure.
So there you go, my views and opinions on why I think a lot of therapists are soft and contradictory towards pain in a lot of their patients. Also how asking some patients to carry on with tasks and exercises that hurt and even to start to do things that increase their pain for a while is not harmful, unethical, or bad. In fact, it could just possibly be the best thing you could do for them.
We all go through life with expectations. We expect our alarm clock to wake us up in the morning. We expect the traffic to be bad on the way to work. We expect a kiss from our partner when we get home. But when something doesn’t go as expected it tends to upset and annoy us, this is human nature, and this is no different for our patients.
I see more and more discussions on social media from therapists about how much they recognise patient expectations are vital to successful outcomes which is great. But what is not so great is how some are using this to justify the use of any treatment, even poorly supported interventions such as dry needles, stretchy tapes, machines that go bing, and of course manual therapy.
Many justifying the use of these low-value interventions claiming they are acting under the guise of evidence-based practice because they are meeting patients expectations. To put this as simply as I can, this is a pathetic excuse.
There is a good deal of evidence that shows how patient expectations are important to predict successful outcomes for many interventions, but this doesn’t justify the use of low value interventions.
For example, one of the strongest predictive measure for successful physiotherapy treatment for shoulder pain was if the patient expects physiotherapy to help (ref). This is the same for chronic back pain (ref). This also applies to treatments such as manual therapy (ref), even my exercise therapy (ref) with higher expectations predicting greater success.
Simply put if a patient thinks an intervention will help them, it will, if they don’t, it won’t. From this, some clinicians have taken the position that they simply need to give interventions that a patient wants or expects to help them get better.
This is one of the lamest excuses and a complete a bastardisation of the research, and really daft lazy clinical reasoning. To put this as clearly as I can managing patients expectations doesn’t mean meeting them.
Just because research shows patient expectations can predict outcome doesn’t mean you do whatever the patient wants. For example, if a patient expects you to give them their massage treatment without your top or trousers on because it makes them feel better, you wouldn’t do it, would you?
So there clearly is a line of what you as a professional healthcare clinician will do to meet a patient’s expectations, which is good. However, in my opinion, this line needs to be much, much higher than it is and definitely a long long way from doing treatments half-naked.
Many patients of mine do NOT have their expectations met, but they ALL have them managed, and I have found if I can manage them well even if I don’t meet them they still get successful results. However, I will be honest and say this isn’t easy and it doesn’t happen all the time.
Trying to manage or change a patient’s predetermined expectation is hard work. When patients don’t know what they want or need and have no prior expectations, these are much easier to manage.
However, more often than not patients do have an expectation of what they want or think they need. This will be either due to some advice or information from another healthcare provider or from some advice they got from a friend or the internet and Dr Google.
In this post-truth world of alternative facts and fake news, misinformation is rife and a lot of patients get some pretty skewed and erroneous ideas, beliefs, and expectations.
As responsible evidence-based clinicians, it is our moral and ethical duty to truthfully inform our patients on what the current scientific literature is saying. During this, we need to remain as unbiased and impartial as we can, which is easier said than done.
We need to present to the patient all the options available with clear, concise information about the pros, cons, risks and benefits, as well as explaining the uncertainty of how these treatments may or may not work. You may be thinking that this is a lot of work, and you’re right it is. But its called informed consent and is a fundamental principle of healthcare.
Meeting someone’s expectations is actually pretty easy, but that’s NOT your job as a healthcare professional. That’s what a receptionist, waiter, taxi driver, or prostitute does. Meeting a person’s expectations is what any good service provider does, however, healthcare professionals are NOT service providers.
Your role as a healthcare provider is to MANAGE patients expectations not automatically MEET them. This means carefully, compassionately, and honestly telling them that sometimes they don’t need what they think they need.
Yes, this is difficult, challenging and requires more time, more effort, often for less reward both financially and emotionally. But, it’s what you signed up for when you decided to be a healthcare professional, and if you don’t like it then I’m sure there are some tables needing waiting or taxis to be driven somewhere!
I often get asked by other physios ”what kind of physio are you?”. Often I reply ‘just an average one’ to wind them up because I know what they are really asking me is what are your qualifications and allegiance to a specific physio method or treatment?
Now there are many kinds of ‘method physio’ such as McKenzie physio, Maitland physio, Mulligan physio, a Cyriax physio, even a Cognitive Functional Therapy physio. And there are many kinds of ‘treatment physio’ such as a manual therapy physio, a pilates physio, a dry needling physio, a cold laser physio, a myofascial release physio, even intergrated functional systems physios.
Well, I am now proud and happy to say I am none of those, I’m just a plane boring bog standard physio. I’m not accredited, affiliated, or aligned with ANY specific methods, treatments, groups or gurus, and personally I don’t think any physio should be.
Now don’t get me wrong I think we can all learn some stuff from many of these methods and treatments, and I have! I’ve personally done many of these courses, jumped through their hoops of assessment and passed their pseudoscientific exams to earn post graduate ’qualifications’. But I don’t align myself with any of these methods or treatments when it comes to doing my day to day job seeing people in pain or with disability!
Personally I think most if not all of these groups, clans, and tribes within our profession cause more problems than benefits producing more bickering, backstabbing, infighting and endless pathetic claims of superiority over each other.
For example, when I was a young naive and impressionable physio I did my first MSK orthopaedic post graduate course with the Cyriax affiliated ‘Society of Orthopaedic Medicine’ or SoOM as its called, I was consistently belittled and looked down upon by those in another MSK orthopaedic special interest group called ‘The MACP’ which used to stand for ‘The Manipulation Association of Chartered Physiotherapists’ but changed its name to the ’Musculoskeletal Association of Chartered Physios’.
Because of this I then started to do my MACP post graduate training but kept coming across so much ego and elitism in their members and tutors that I left half way through my training unable to stomach it or them anymore. Still to this day because of these experiences I hold the MACP and most of its members in low regard. I have also had some personal and professional disagreements with some of their senior members and have found the MACP to be a seething nest of spiteful, vindictive, and narcissistic attitudes and actions.
The MACP often try to promote they are working hard to improve the standards and advance MSK physio, but in my opinion this is just a thin disguise for their real motive which is to get as many physios as they can to join their clan, pay their subscription fees, do their training, jump through their hoops of assessment and accreditation, and ultimately think and act exactly like they do.
I’ve lost count of the number of times I’ve seen or heard MACP physios thinking and acting the same, often claiming that they are better trained, better skilled than other physios because of their membership. Many think and have told me that because I haven’t completed the MACP training brainwashing or jumped through their hoops of accreditation that I am somehow less skilled, less capable, less of physio
I often get called by many MACP members in senior ESP, APP, FCP roles a ‘glorified personal trainer’ in some misguided and laughable belief that this is somehow an insult to me. Many think that because I dont use manual therapy, electrotherapy, dry needling, taping, or any other adjuncts to help people with pain or disability, preferring to use advice, education, movement, and exercise that I am not fit to call myself a physio.
Many think that because I dont use any passive treatments, tricks, gadgets or gizmos then that makes me less of a physio! This makes laugh and cry at the same time
For example, when some physios call me a glorified personal trainer it clearly shows their arrogance and ignorance in thinking that personal trainers are somehow beneath them. Even though personal training is largely an unregulated profession I think many, many physios could learn a thing or two from some personal trainers.
A lot of physios like to belittle or ridicule personal trainers for their lack of knowledge on anatomy, biomechanics, or because they don’t have formal qualifications or protected titles. However, when it comes to exercise prescription, planning, and programming most personal trainers put most physios to shame.
Physios are thought to be the ‘experts’ of exercise but I know first hand that most physio training does a really shitty job at educating and equipping them to understand, prescribe and program exercise effectively. Most physios training on exercise and rehab tends to reach the dizzying heights of how to prescribe safety googles before using Thera-band and how to walk up and down a flight of stairs, which can be important, but let’s not forget that without sufficient leg strength no one is walking up or down any stairs anytime soon.
So you would think it would be a good idea for physios to also learn how to develop sufficient leg strength in their patients. You would think it would be a good idea for the universities or special interest groups like the MACP to teach physios how to perform and teach exercises such as the squat, the deadlift, the overhead press, and many of the other basic strengthening exercises. Yet they don’t!
Most MACP or other accredited method/treatment courses couldn’t teach you the difference between a front squat, back squat, sumo squat, goblet squat, hack squat, pistol squat, split squat, half or quarter squat, let alone demonstrate them well. Most physios training does not teach them how to prescribe, dose, progress, regress, or execute exercise well.
Most physios training is just not focused on exercise or rehab, but rather on modalities and adjuncts like manual therapy, dry needling, and taping etc. Many physios are lead to believe that these treatments justify their role and their place in the healthcare system, and exercise is the simple easy bit that can be done at the end, or worst not at all!
This makes me both mad and sad. Physiotherapy is so much more than its treatments of manual therapy, electrotherapy, needling, even exercise.
Many physios feel the need to justify their existence by saying things like they break up scar tissue, release stiff joints, free fascial adhesions, or correct muscle imbalances or faulty biomechanics. Many physios just don’t feel confident to explain that what they do is assess, reassure, advise and try to get people moving more.
Many physios feel the need to exaggerate and conflate what they do to make themselves feel more important and more essential in the eyes of their patients, their peers, and other healthcare colleagues. Many physios just do not get taught or encouraged to see the value in simple, honest, things they do.
This is again both sad and maddening.
So I will try to change this by saying that as a physio I try help people inpain or with a disability to move and function better. I do this by assessing for any serious or sinister stuff, then advising and reassuring patients that its safe. I then try to look at ways to get them to move differently, get them a little stronger, fitter, and more robust both physically and psychologically.
I do this without any gadgets, gimmicks, magic tricks, or bull shit. I don’t correct faulty biomechanics, I don’t release fascia, I dont alter soft tissue tightness, spasm, tone, or flexibility, and I don’t miraculously cure or remove pain.
I wrote an editorial for the Aspetar Sports Medicine Journal called ‘divided we stand‘ you can read it here. In this, I discuss barriers and divisions that I’ve encountered between academics and clinicians working together. This has created a lot of debate and discussion and is exactly the reason why I wrote the piece.
However, unfortunately, most of this debate has been focused around my so-called offensive style and tone rather than the issues I raise, with accusations of me having an agenda, being negative, even anti-academic.
First things first, I am NOT anti-academic. But I am anti-egotistical, anti-hierarchical, and anti-progressive with those who try to prevent others from highlighting issues, asking questions, or challenging ideas. I do appreciate that my views agitate some, but to complain about my tone or to accuse me of ulterior motives is a diversion from the main point I am making which is the continued gap that exists between most academics and clinicians working together better.
It appears that those who have taken the most umbrage with my editorial are those who have very enviable positions, the academics and so-called ‘clinical academics’. These individuals have managed to obtain some fantastic job roles which are able to combine research and clinical time.
These roles are a split between paid research and teaching time, usually attached to a university or other academic institution, and paid clinical patient contact time.
However, these roles are rare, and the individuals in these roles appear to have a rather skewed view on what is happening outside of their utopia. I have no doubt that they do see close, effective, productive, rewarding working relationships between academics and clinicians which is great, but again I will state, these are rare!
Most academics are full time!
Most academics don’t do any clinical work. Most academics focus on teaching and researching, and in my experience, most academics go into teaching and researching to ‘escape’ from patients. Having talked to many full-time academics about clinical work and if they miss it I usually get a reply of “oh hell no!” or “not at all”
Most academics I speak too are usually tired and frustrated of clinical work and have no intention of going back either due to the workload, financial constraints, the environment, or the lack of results and outcomes, and I can understand and empathise with this.
This is not to say all academics are this way inclined. Some do still see patients and enjoy the challenges of both clinical and research work as well as helping and supporting others do the same. And this gets nothing but my utmost respect and admiration, but again I will state that this is not common.
Most clinicians are full time!
Most physiotherapy clinics in the national health service and in private practice employ physios to do one thing. See patients. That’s it! The ever-growing demands on hospitals and physio clinics mean most employers want their clinicians assessing and treating patients when ‘on the clock’. Most employers do not want their clinicians reading, researching, or doing what is usually seen as frivolous or fruitless with no financial gains or reimbursement during their time.
So I will say again just as I did in my original editorial that it is these differences between academics and clinicians that are some big barriers to the future progress of trying to implement research into clinical practice. This needs to change, and yet again is why I also wrote the editorial.
What we need is more clinical academic posts, we need more paid, well-supported posts that help implement and push research further and faster into practice!
The usual clinical academic!
Currently, if a full-time clinician wishes to do some research the reality is they have to do it in their own time, using their own resources, without getting paid. And many, many do this. Myself included. I have over the last few years been dabbling in some clinical research, and its been hard work.
It’s not that I expected it to be easy or a walk in the park, I knew I would have to sacrifice time, energy, and some money to do this. I just wasn’t expecting how much. For example just to get one ethics board to review one submission of a trial I was working one last year it was £1500. I estimate I’ve worked over 200+ hours unpaid, not to mention the countless late nights and weekends sat at my desk reading, researching, missing out on family and other social time.
I wasn’t expecting many of the other barriers I also came across, such as being ignored by some institutions as well as by some well-respected academics when I reached out for some help and guidance, even receiving a few short sharp refusals from some.
In a nutshell
So when I was approached by Aspetar to write something on the issues around the difficulties of implementing and getting involved in research, I thought this would be a perfect opportunity to highlight what I have experienced.
I try to point out some of the flaws in some of the academics I have come across. Things such as being too analytical, too hierarchical, too busy to help clinicians do research. But I also highlight some flaws in some of the clinicians I have also come across, such as being too lethargic to get involved in research, having a poor understanding of the scientific principles, and being too busy to look up from constantly treating patients and realising things need to change.
I also discuss some of the barriers that these two groups have in working well together such as difficulties in communication, lack of time, resources, and funding. And I finish off by saying let’s get our shit together, put aside the egos and hierarchy and start working together better.
This has created a lot of feedback from the clinicians with many sharing their own frustrations and stories of issues and barriers they encountered when to trying to get involved in research. However, there has also been quite a lot of complaints mainly from academics who seem to think I have created more barriers with this editorial.
I just think this is nonsense from a few bruised egos. Highlighting issues and suggesting ways forward in my opinion doesn’t hinder progress. Bitching, moaning, and complaining about tone and offensive style whilst burying your head in the sand and refusing to accept or listen to others experiences does!
“Rome wasn’t built in a day” is a saying that is often used to describe issues that take time to resolve. Change and progress takes time, but to move forward we need to highlight issues and barriers. And although Rome wasn’t built in a day, there is also another saying “there are many ways to Rome” to highlight that if current progress is stalled, take a different route!
I don’t know about you, but I’m ready to move forward and take another road because the one we are on doesn’t seem to be going anywhere.
I was just gonna let this go but then I thought why should I, just because you are usually right doesn’t mean you are always right, and for once I think my good buddy Greg Lehman is wrong.
Before I get into it let me explain what a ‘straw man’ is. A straw man is a classical logical fallacy of which there are many. Logical fallacies are errors of judgement and reasoning first described by Plato and Aristotle. These occur often when debating, discussing, or arguing the toss over the utility of symptom modification techniques.
The straw man is easily one of the most common logical fallacies. It is when someone distorts, exaggerates, or misrepresents your argument to make it easier to attack and knockdown. For example, saying teenagers should be taught more about safe sex, is often straw manned into saying teaching teenagers about safe sex makes them more promiscuous.
Anyway back to the subject at hand. Greg did a little counter blog here to my recent blog here on the role of symptom modification techniques, as well as commenting on a tweet I posted the day after here. Unfortunately in Greg’s blog he quickly builds a straw man by claiming I don’t think symptom modification techniques are important.
This Is Wrong.
If you are really, really bored read my blog again and you will find nowhere in there is my ‘position’ that I think symptom modification techniques are not important. In fact, I state just the opposite, I state when they work they can be fucking awesome.
My position is that symptom modification techniques that are taught or promoted by those that use them, be that the Mulligan-ites, Maitland-ites, McKenzie-ites, Lewis-ites even CFT-ites, all these techniques are up for questioning and challenging.
My position on symptom modification is questioning their necessity and their predictive value, and their mechanisms of effect. Be that joint mobilisations, spinal manipulations, taping, massaging, scapula assisting, corrective exercising, psychological interventions, even education. Because in my opinion, all these modification things are very uncertain and very unreliable.
This is NOT saying they can not be used or are unimportant.
I question the need to use symptom modification techniques with those in pain. I question the bio-mechanical explications that are often given when symptom modification techniques work. I question the need to do symptom modification techniques in a procedural format. I question the predictive value of symptom modification techniques. And finally, I question that symptom modification techniques do not ‘dictate’ our treatment decisions.
Dictating is not Guiding.
Dictate is to “lay down authoritatively; prescribe; boss around; give orders to”
Guide is to “have an influence on the course of action; direct; steer; manage”
We all know that language is important on the effect it can have on our patients. We should also be aware of the effect language can have on us. So when we say we can dictate a treatment is in my opinion to prescribe without thinking.
For example, the scapula assistance test is a simple and commonly used symptom modification technique used for shoulder pain. You press around the scapula as the patient lifts their painful arm and if it’s effective the pain is reduced. Great, but what now? How do you explain it? What do you do with this finding?
Many will say that the scapula assistance test increases the subacromial space by facilitating more scapula upward rotation and posterior tilt. Therefore you need to prescribe scapula exercises that promote upward rotation and posterior tilt, or that you need to use taping techniques that do the same.
This is a test dictating treatment. But this is not recognising or acknowledging the uncertainty of the effect of the scapula assistance test. This is flawed clinical reasoning.
I occasionally get great results with the scapula assistance test, but it doesn’t dictate to me what I do next with the patient. In fact, it often leaves more confused due to the uncertainty of why it worked in the first place.
I actually don’t scapula assistance tests have much to do with scapula upward rotation or posterior tilting most of the time, and it certainly doesn’t mean I have to give patients scapula rehab exercises focusing on upward rotation and posterior tile.
Instead, a successful scapula assistance test for me often ‘guides’ me to discuss with the patient about how quickly their pain can come and go, and how this means that they have a favourable prognosis and how their pain doesn’t mean there is a serious structural problem and how it is not to be feared or afraid of.
In my opinion, a scapula assistance test is more a tool that ‘guides’ education rather than a technique that ‘dictates’ a treatment, and this goes for all the other symptom modification techniques. A successful spinal manip doesn’t tell me which exercise to give, a successful MWM doesn’t tell me which structure is at fault. It’s just not that simple.
Greg is wrong, but I still love him! And I don’t think nor state that symptom modification techniques can not be used. I just think they are not necessary. Please use symptom modification techniques if you want, just don’t waste to much time on them, and just be aware of the uncertainty of how they work, and the potential negative effects they can have if they don’t work. And finally, don’t let them dictate to you what you can or should do next.
Creating a change in our patients pain and symptoms is really important. That goes without saying. Or does it? There is no doubt that patients come to see us wanting/expecting a change in their pain and symptoms. But how important is it for us to get these changes? Do we have to change things a little or a lot? Do we have to change things quickly, or slowly? And do changes in patients symptoms help us choose better treatments or predict their prognosis?
Well, there are many therapists who strongly advocate and promote the importance of achieving significant in session changes for our patients. For example Maitland and Mulligan and their mobilisations, McKenzie and his repeated movements, even Lewis and his shoulder symptom modification procedure, all advocate that the key to success is in finding in session changes for all our patients.
There are also the myofascial releasers, spinal manipulators, dry needlers, K-tapers, machiners that go buzz who also promote and bombard us with claims that getting quick and significant changes in our patients’ symptoms helps them buy into our active treatments and improves our outcomes and success rates.
Despite these claims, I don’t think we need to change things that much or that quickly for many of our patients to have successful outcomes. Now as a young, eager, and rather annoying junior physio I was taught to always test-retest everything and anything with every patient I saw. I was told to get the patient to do something that was painful, or restricted, or difficult and then do ‘something’ to try and change it. This usually involved me pulling, poking, rubbing, or zapping the patient with something.
Now when it worked it was an awesome feeling. The patient thinks you are a miracle worker, you feel great knowing you have made a difference to someone in pain and distress. The patient feels good, you feel good, the world feels good, it really is a good feeling, and I was lead to believe this was how I should always work and measure my success as a physio.
However, it didn’t take long before I began to feel disheartened and disillusioned with this because the uncomfortable truth that no one ever talks about is that these sudden and significant in session changes don’t happen that often. In fact they happen rarely. I would say that for every patient that got a successful in session change there were about 10 others that didn’t. This is what the gurus don’t tell you, they don’t admit that usually most patients will say after some poking and prodding… meh, nothings changed, its kinda the same, or even sometimes it now feels worse! This didn’t feel so good, this feels like I’m a failure!
But I kept plugging away over the years trying to create these in session changes in my patients getting told to keep practicing and I would get better at it. I didnt! However, over the years I came to realise that it didnt really matter if I got some patients feeling better there and then, as those who I did get some in session changes with and reduced their symptoms quickly didn’t always get better, and those who I didnt get any changes with did improve just fine.
I also began to realise that all the techniques are unpredictable and unreliable, and when they did work they all varied in how much and how long the effects would last for. And before you go and say this is due to my lack of skill or experience in how I apply or do these things, I will say that’s a load of bull shit (ref). And before you then go and say its because I don’t use them on the right patients, that’s also a load of crap (ref, ref). I will, however, accept that some experience gained to develop comfortable handling and confident application of said poking and prodding may have helped a little, but this is NOT the only factor that determines success or not.
I have seen many times with my own eyes that I can do the same technique, the same way on two different people with the same issue and get completely different results, and over the years I have come to realise that these in session changes are not actually needed for me to get successful outcomes for my patients.
Now the evidence about the need for us to create in session changes to help guide treatments and predict successful outcomes over the course of time is limited. But there is some, mainly in low back pain (ref, ref, ref). However before you get too excited it is important to consider that this is by no means robust evidence.
First these studies look at very short time periods and don’t compare against a control group of no treatment. Also the confidence intervals of the positive association of those with in session changes are widely spread, meaning we have little confidence in the power of the association, it may just be that those that get in sessions changes would get better regardless of what we did. And then there is counter evidence in shoulder pain that in session changes do not predict outcomes or help dictate treatment options (ref)
So although its can be nice to get quick significant in session changes for a patient and it may increase the chances of them improving sooner, they are by no means necessary or definitive.
Once I stopped constantly trying to create these in session changes with my patients I began to realise that they were often only a distraction from getting to the more important stuff of discussing and exploring ways and means to create long term changes and get them of the shitty quick fix healthcare merry-go-round.
In my opinion we are living in a world of slowly dissolving self efficacy. We are a population slowly losing the ability to look after ourselves. We are a generation that fails to take any responsibility or control for our own issues. We are a species that has lost sight of what is hard, difficult, or challenging. In today’s society of quick fix, instant gratification, someone else’s fault, we look to blame others, hand over responsibility, and take the easy path. We are devolving, and in my opinion modern healthcare has a huge role in this catastrophe.
Of course, modern healthcare and medicine have undoubtedly saved millions of lives as we understand and treat serious diseases and injuries better. I am not questioning this. But when it comes to the not so serious shit, the shit that just gets better, the shit that should not cause any major issues, for any significant time, the shit that can be painful, annoying, and frustrating, but wont kill you, the shit that most physios see, it is healthcare’s meddling and interfering with this shit, trying to reduce, correct, and avoid it that has helped to screw us up as a species.
In my opinion, all of us who work in healthcare be that physios, docs, surgeons, etc simply need to get better at reassuring patients that nothing needs to be done. I often find myself as a physio at the bottom of the shit heap with patients that have been pushed from pillar-to-post having tried this and that for their problem, and all it has done is made them more confused, more worried, more painful, when all that need to be said at the beginning was this is ok, nothing much to worry about, it will get better, keep moving.
Simply put we all need to get better at convincing and educating most of the people we see that they don’t need that injection, that tablet, that massage, that tape or whatever your quick fix of choice is. Yes this takes longer to do. Yes this is harder to do. Yes this is an arse ache to do. But that’s no excuse to roll over and take the easy option.
If we as healthcare professionals are not prepared to take the harder path, then why should we expect our patients to do the same. We need to lead by example. We need to stop looking for the easy yet unpredictable, unreliable quick fix, and focus our efforts on the harder more stable, more reliable, more challenging long term changes.
As the late great David Bowie said…
Ch,ch, ch, changes… turn and face the strange,Time may change me, but you cant change time
Now I’m not entirely sure what the white duke is getting at here, and i’m not sure it fits with my closing thoughts but it only seems fitting to finish with his lyrics seeing as I used his song title for this blog. So in summary we need to create changes for our patients, but these don’t have to be the quick instant changes in pain that many advocate. I don’t care if a patient leaves a session with me feeling the same or even worse. All I care about is does the patient feel safe, reassured, confident and in control of their own ability to get through this situation. In my opinion we need to shift our, and the patients attention away from the quick change and look to creating the long term changes.
As always, thanks for reading
I often question the effectiveness and usefulness of many things us physios do, and I often take the position that doing less is more. I believe that most treatments and adjuncts to the core principles of education and exercise offers little benefit to patients. This often upsets people and often I get embroiled in debate, discussion and disagreement around this.
I recently had such conversation when I said I am seeing more people moaning about how they think manual therapy is getting a hard time, and how I think this is a good thing and how I think the crap that surrounds manual therapy needs to be questioned more often, not less.
However, some thought that I should be just as critical of other aspects of our management such as our core interventions of education and exercise. And I agree, we should be equally critical of these things. I am well aware that there is little ‘robust’ evidence for anything we do as physios and I am well aware and mention often that things we see often get better regardless if we rub, poke, or exercise them, things often just get better regardless (ref).
This is called natural history and its is physios and healthcare’s dirty little secret that is never talked about, and when it is, it upsets people who can not accept that they are not essential or needed as much as they like to think.
Now it wasn’t long before a few others joined the discussion with most looking to defend the use of manual therapy, and as usual some got frustrated with me and my opinions, if you’re bored witless you could read the full thread here. Anyway the discussion went on, and it went off on a few tangents talking about steroid injections and shockwave therapy, and after about 250 tweets later no one had changed their views or opinions and nothing had been resolved.
But this is ok, this is what debate and discussion is about, and believe it or not I don’t expect to change peoples views or opinions at all, and although others find it frustrating and a waste of time and energy, I often enjoy these discussions, they make me think and question my own thoughts and ideas which is never a bad thing.
But often in these discussions I do find that some knob head starts getting their knickers in a twist because I won’t change my views or opinions to theirs, or they complain about my tone or attitude and starts to get personal and falls foul of the logical fallacies. It does still amuse me the amount of angst, outrage, and frustration that some have when I challenge or critique their cherished treatments and wont change my mind.
Anyway back to the point in issue, I am now quite comfortable in doing very ‘little’ with most of my patients, preferring to stick with the core principles of physio by giving advice and education, encouraging moment and then loading it.
My simplistic approach has been neatly visualised here…
Its so clean, simple and beautiful it makes me weep just looking at it…
However this simplistic approach is not easy and it’s not doing nothing, in fact it is a hell of a lot harder than it looks, doing little actually involves doing a lot.
Simple is hard, if you don’t believe me, try it. Try not give that next patient a massage, some tape, or a machine that goes bing when they want it. Try instead to talk and discuss with a patient how short term gains may lead to long term issues. Try and educate a patient on the passive therapy merry go round who has some deeply ingrained beliefs and expectations about passive treatments that they need to take a more active role in their condition and take ownership of their own problems.
Try NOT doing some things and then tell me its fucking easy!
However, just because I often don’t do other ‘stuff’ and I question and critique treatments such as manual therapy or injections doesn’t mean I think they can NEVER be used!
As a physio with many post graduate manual therapy certificates and as an extended scope practitioner trained in diagnostic ultrasound and injection therapy I have manipulated, massaged, and injected many patients.
I do understand that at times strong patient expectations are to be respected and that when a patient believes something will work, it will work (ref). But this doesn’t mean we should do what a patient wants or expects, as sometimes a satisfied patient isn’t a healthy patient (ref). However, lets be honest not many patients die from a bit of massage or a injection, and so if there is no clear risk or detriment to a patient, some manual therapy or an injection from time to time isn’t the worst thing to do. But we shouldn’t stop questioning or challenging the effectiveness or usefulness of these things, as well as highlighting the often over looked negative aspects of these treatments.
I think its essential that as a profession we are more critical and skeptical of all we do, in particular with the things described as adjuncts. Things such as manual therapy, taping, electrotherapy, and all the needle therapy’s such as acupuncture, dry needling, steroid, PRP, scelerosing, or stem cell injections. Do any of these things actually do anything of any significance, are they worth the time, money, and resources, but more importantly do they have any negative effects.
Lets first look at corticosteroid injections which have been shown to have deleterious effects on tendons (ref, ref, ref), and although they may offer short term benefit in lateral elbow pain, they have been shown to offer no added benefit in the long term and may actually be detrimental (ref). Finally a common justification for these injections is that they can help patients do their exercises more often or better also appears to be questionable (ref).
Next lets look at manual therapy which has been shown to offer no benefit in chronic low back pain (ref) or acute low back pain over sham or inert interventions (ref). It appears there is no benefit of one type of manual therapy over another (ref). And adding manual therapy to exercises doesn’t improve outcomes (ref). Finally manual therapy could reinforce to our patients that their pain is tissue or structural based and that its needs to be reduced or modified or that its harmful or damaging (ref).
In my opinion manual therapy may actually be one of the reasons why we have seen very little improvement in the prevalence of back pain globally over the past decade. The constant desire by patients and clinicians to reduce pain with medications, injections, and manual therapy, may actually be reinforcing negative beliefs and causing people to become less resilient, less robust, and less tolerant to pain.
Lets do a little thought experiment. Lets pretend that the healthcare system you work for is struggling with funds and resources. That it is over whelmed with demand and under staffed. Lets pretend that you as a physio have just 6 x 30 minute sessions to make a difference to someone who has had pain for 6 months, who is confused and worried about what is going on, who is afraid of making things worse, who is fearful to move, who has a million questions. What would you do? What would you prioritise as essential in your limited time and resources? What if a patient was paying themselves, would this change anything?
I work in both a struggling healthcare system and private practice where patients pay for my time. For me it doesn’t matter where I am working, its still the same. I always prioritise advice and education, encouraging movement, and loading it, this leaves little to no time for anything else. I never became a physio to rub or poke people. I never became a physio to stick needles into or tape onto people. I became a physio to restore thoughtless, fearless movement to people in pain and to promote the benefits of a healthy and active lifestyle. I became a physio to help others who are struggling with life due to pain or injury. I became a physio to get people moving more, to get them stronger, to get them more resilient. And I find the less I do things to people the better they get at this. I find doing less is more, more or less!
As always, thanks for reading
The desire to help others is very strong in many therapists, that’s usually why they are therapists. But sometimes this desire to help and do something may actually be to the detriment of those they are trying to help, and without realising it therapists may be doing more harm than good for many of their patients.
If you have been watching the Olympics then i’m sure you have seen a few of the athletes in the USA team appearing with neat circular bruises created by this ‘cupping’ treatment that has generated a lot of discussion and debate on social media, some for it and some against it.
Michael Phelps ‘wearing’ cupping marks
This ‘cupping’ treatment dates back to medieval ages and is believed to help reduce muscle soreness and aid recovery by lifting the skin under a suction effect beneath a cup hence its name. This suction is believed to increase blood flow and flush out waste products, toxins etc etc from muscles and tissues beneath. It doesn’t.
It simply creates nice neat circular bruises from the pressue under the cup rupturing the small capillaries in the skin, and if I remember my basic physiology correctly bruising the skin and creating rings of stagnated blood does NOT help your muscles or any other tissue recover or heal quicker. If it did i’d be punching and kicking my patients until they were black and blue all over. Personally I think its a daft treatment and I can’t see the point of using it in any situation.
But anyway its not cupping that we should be criticising per se, rather it’s the ethos and mentality that many therapists have who feel the need to do something like cupping. Why do so many therapists use these daft, stupid and sometimes harmful things rather than just do nothing?
Why is doing nothing rarely an option for many therapists?
Regardless of therapist experience, training, or setting, be it in elite sport to your average NHS out patient department I see and hear many therapists doing some werid and whacky shit to their patients rather than doing nothing.
Is this simply their desire to help, or are other factors at play?
Be it cups, tapes, lotions, potions, machines that go buzz, needles, needles that go buzz, injections, and of course manual therapy and manipulation. Many therapists just want to ‘do’ things in an effort to reduce pain and promote recovery that little bit more, that little bit quicker, that little bit extra, that 1%.
These so called 1%ers have also been the topic of discussion recently with some defending there use for some, such as elite level sport, and others have have questioned there worth and the potential harm they can do.
Now I dont think cupping is that risky per se, some bruises and looking like a polka dot twat for a few days being the worst risk for most. However what are the benefits? Well unfortunately there is no real evidence that any of these 1%ers actually do give that extra 1%, either physical or psychological. Some say thats because its hard if not impossible to measure these small effects, others because the science hasn’t caught up with the advanced nature of the treatments yet.
Usain Bolt getting his 1% treatment after his recent hamstring strain
However there is another explanation thats more plausible as to why we cant see these 1% effects. Perhaps they don’t actually create any effect. Perhaps they are only a placebo. Now I don’t want to get into the debate over the pro’s and con’s about using the effects of placebo, that has been done before many times ov