Less is More… More or Less

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.

Nothing changed!

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!

Respect

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.

Detrimental?

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
Adam