When a patient tells me they have read something in the newspaper about back pain my heart sinks and my left eye starts to involuntarily twitch as usually its some ill-informed garbage about a quick fix, or drivel about a miracle cure that I have to try and convince them is utter bull shit. But from this week there is hope that a patient has at last actually read something useful about their back pain in the media.
This week The Lancet published three very important papers about back pain. These papers authored by the worlds leading researchers highlight how back pain is a huge global burden affecting millions if not billions of people worldwide, and how it is getting worse despite advances in healthcare, medicine and surgery. Please go and read these papers here, they are freely accessible and well worth an hour of your time.
These articles highlight how back pain is often grossly mismanaged and over treated with many ineffective and dangerous treatments such as surgery, injections, and medications, but also how the less harmful but equally ineffective low-value treatments such as manipulations, massage, and acupuncture are wasting time and resources for patients and healthcare providers alike.
There has been huge interest in the media across the globe in these papers with all the major newspapers such as in the UK the Guardian, the Telegraph, and even the shitty Daily Mail running articles on it. Also, the tv channels such as The BBC have been running stories on it, and for once the media are doing a fairly good job in sticking to the facts, mostly, and sensibly reporting the findings thanks to the great work of the authors of these papers.
This is really encouraging as hopefully, at last, a lot of patients with back pain as well as the general public will read these and get some rationale sensible information about back pain. Simply put all these articles are challenging the way most view, approach and manage back pain and about time.
These articles ask us to recognise that back pain is a normal part of life and most episodes are not serious and don’t need any formal treatment. They tell us that low back pain is a complex condition caused by a multitude of factors, both mechanical, environmental, and psychological, but just because its complex it doesn’t mean its management needs to be complicated… Complex doesn’t have to be complicated… now, where have I heard that before?
These articles tell us that most episodes of back pain are self-resolving and don’t need time off work, don’t need painkillers, don’t need manipulation or acupuncture, and most certainly don’t need surgery or injections. Instead what they tell us is back pain needs to be effectively and efficiently screened for the rare but serious causes and then managed with reassurance and advice to keep active and positive.
This is music to my ears as it’s something I and many others have been trying to promote for years in trying to move clinicians away from overtreating back pain, in fact, all pain. However, not treating back pain doesn’t mean do nothing and don’t help.
Many people with back pain will still need help and assistance, but this is often just good simple, clear, honest, advice, education, and reassurance, which is undervalued by clinicians and patients alike, and often considered as doing nothing but really is doing a lot.
However, there are many barriers to ‘only’ giving advice and education, the first and most important is the financial reimbursement for ‘not treating’ people in pain. Unfortunately, in most private and even some public sectors, many clinicians get rewarded for doing things to patients and not just for their time and advice. This incentivises the clinician to over treat and until this changes, nothing else will. High fees for injections, surgery, specialist massage, manipulations and machines need to be eradicated, and flat fees for consultation time regardless of treatment need to be established.
The next barrier will be to get healthcare professionals comfortable and confident ‘not treating’ those in pain. Most who work in healthcare are caring empathetic individuals who want to help others in pain and distress, and so the desire to do something is strong, and the more desperate the patient the more likely the clinician will intervene. Desperate patients, unfortunately, create desperate clinicians.
The other significant barrier to ‘not treating’ will be to get patients to accept that ‘no treatment’ is in their best interests. Most patients see ‘no treatment’ as lazy, cheap, and uncaring and this can drive them to seek others, usually the quacks and charlatans who will give them what they want. Therefore we have to be very very careful in how we word, frame and do ‘nothing’ to avoid driving our patients into the waiting arms of these shysters.
Often for me, the key factor here is developing good rapport and trust with your patient quickly. The stronger this is, the more likely they are to accept your advice and ‘no treatment’ and this is why I am so passionate about getting more clinicians to recognise that it’s not WHAT they do that really matters but HOW.
So there you go some good news in the media about back pain at last. I’m positive that this will help the general public as well as us clinicians to promote a more evidenced-based, rationale, simple, and effective way forward for back pain. But don’t be fooled into thinking it will be easy or simple, it won’t, it will be challenging and difficult but that’s why we continue to do what we do hey!!!
As always thanks for reading…
Adam
Hi Adam,
That’s a great read. I am a physiotherapist from India and have been trying to incorporate these principles into my practise since I did some study into pain sciences.
I agree to your point that all of the above mentioned interventions don’t help patients
I have lost quite a few patients because patients expect hands on treatment .
I have tried to educate them but I’m the bargain have lost clients who then go on and get hands on treatment somehwhere else.
How do you deal with that ?
Hi Urvashi
We just have to accept that patients have a choice and some will seek the treatment they want, not what they need. Dont worry to much about it.
Cheers
Adam
Thanks for sharing. You are absolutely right. No treatment does not mean that no intervention is done. As a Professor and physiotherapy educator, I am trying hard to convince my students that educating patients about their pain is one of the most powerful tools we have in our hands as therapists. In fact, education is now recognized as a critical component of any pain management program. The problem is always that students get conflicting perspectives and opinions when going from an ortho class to a pain class. Every time I have to deconstruct their beliefs based on the biomechanical model (pain= structural lesion) with more or less success. They graduate and then rush to manual therapy and McKenzie approaches… .
Hi Francois, thanks for the message and I agree it is hard and frustrating when we have so much disagreement and resistance to progress within our profession. All we can do is keep going and try and promote what we can, where we can.
Cheers
Adam
Hi, François, as far as I’m concerned, the McKenzie method does not emphasize biomechanical components and strongly educates its students of the biomechanical model’s failings in all of its classes. It talks about studies where they show centralization despite no MRI changes happening at the disk and other very interesting studies including all the classic ones showing how a lot of people with no history of LBP have herniated disks. They tell you to try the McKenzie approach (look for centralization) and then stick to the McKenzie prinicple if centralization and/or a quick mechanical response happens (if we’re dealing with a derangement). On the other hand, once you fall into a group that does not respond to McKenzie (OTHER SUBGROUP), then you treat them just like Adams would: general, non-specific exercise for non-specific LBP. There’s also dysfunctions and postural syndromes, that MDT tells you to treat with strict Mckenzie, but those are super rare. In short, the Mckenzie method is a classification system, not a biomechanical model, or at least it is thaught that way now. Cheers.
Adam, do you see any of these recommendations making it to the implementation stage?
Tackle vested interests
• Government, insurers, and commissioners should consider
tackling conflicts of interest through regulation and
contracts, including not paying for inappropriate tests and
for unnecessary, ineffective, and harmful treatments
• Existing and new tests and procedures for low back pain
should be regulated in the same way as drugs; evidence
should be available showing that they are safe, effective,
and cost-effective before they get reimbursed within public
health-care systems
• Introduce incentives for effective and efficient care and
disincentives for continued use of ineffective and potentially
harmful approaches
Hi John
Good questions, simple answer is not until we have some of the most up to date evidenced based clinicians in governmental positions influencing policy and finances.
Hi Adam. I more likely scenario is for third party payers of therapy services to employ “approved therapists” to review individual management plans before agreeing to fund them. It is already happening in Australian systems of Workers’ Compensation.
I feel like your point re: patients not accepting getting no treatment thus leaving for someone who offers a “quick fix” is a MUCH larger barrier than you give credit for. It would require an entire cultural shift in society to see front line clinicians in a consultative light, and not as healers.
Healthcare has only just recently moved out of the paternalistic healer model where “sick” patient goes to clinician expecting them to “do something” to them to make them better. We are far, far away from a self-care model where people take ownership of their own health. How many people still go to their GP for the common cold (not counting those that just need a sick note for work or something)?
I agree this is a societal issue not just a physio/healthcare issue
So, how do you treat your non specific with no red flag back pain patient with advice?
By educating and reassuring them that most back pain is nothing to be worried about, to keep active and that it will get better on its own.
Still a long way to go judging by the response I received after sharing your post!
“Ok I reread this. I will say what I think despite this research.
I See what he is saying… but for fucks sake, really!! He thinks a hands off treatment is appropriate… does this guy even have an ounce of compassion? This guy is a healer right? Maybe he isn’t. Physio and healer don’t always go together.
Just as researcher and healer definitely don’t have a fucken one to one relationship!! Haha.
Soft tissue therapy is still unknown in the world and the power of it is life changing for people….. and this isn’t only because of the techniques within it.
Just as this article is saying, reassurance and support and trust are paramount. This comes across to the client due to three elements.
1. Your positive friendly want to help that person as much as possible presence.
2. Your confidence in everything you say and do. This comes from your experience, the catalogue you have accumulated based on similar cases and your scholarly knowledge.
3. Your technical skills in manual therapy, tissue / orthopaedic assessment skills and clinical reasoning.
This all needs to come across in the treatment session.
Many back issues require movement re-education. I can see where a hands off approach is needed here… but for fuck sake you had better be tapping their glutes for better neural activation, verbally cueing the hip to fold etc.
It seems this guy doesn’t realise or underrstand that under functioning glutes or core will overload a back.
Hip flexor dominant clients that cannot switch glutes on can aid in the brain finding the glutes by releasing tone in the illiopoas. It doesn’t take much hands on work to realise the importance of this!! That’s if he actually touches his clients!!
For fuck sake.
No wonder our clinic is busy as Fuck and the same with clinic 88 and anyone else with real soft tissue therapy skills.
For sure surgery is scarily advised way too early. Back pain is frightening for people especially when it threatens their career and lifestyle, that’s the whole problem with pain hypersensitivity, the amagydala and hippocampus go nuts. And let’s be real some people despite the warnings just like being cut open”.
Not sure how or if I should respond?
Cheers’
Ben
Sweet Jeezzzzuz… I dont if I should laugh or cry at these comments. So much cognitive dissonance and narcissism here thinking that manual therapy ‘heals’ or therapists are ‘healers’. I hate that thinking.
Oh well guess I and the others who are trying to promote a more rationale simple evidenced based way still have a long way to go, and we will continue to pick up the pieces of those patients they see and misinform with pseudo science and nocebic nonsense.
Cheers
Adam
Reblogged this on Neil Wise Physio and commented:
Keep spreading the news….concise as usual for thesports.Physio @AdamMeakins