You may have seen the recent media campaign by the UK Chartered Society Of Physiotherapists about challenging some of the common myths around back pain, if not you can read it here. This campaign was launched across multiple media channels including tv, radio, newspaper, and of course social media. It was aimed at educating the general public about some of the incorrect beliefs around back pain. It achieved a huge amount of coverage and attention and generated a lot of feedback from the both the healthcare profession and the general public. However, some of this feedback was rather negative and a recent editorial in the BJSM here discusses this and some now think the mythbusters have themselves been busted.
Following this editorial by Dr Chris McCarthy who along with eight others, including myself, was a member of the working group that helped develop and plan this campaign, there have been some rather disappointing comments and reactions on social media. So I thought I would have my say about this, and also put the record straight about a few things that appear to have been misinterpreted about Chris’s interview to the Daily Mail, his editorial, and the myth busting campaign in general.
In the BJSM editorial Chris explains his ‘bruising’ experiences of the direct, harsh, and annoyed comments left by the majority of the readers on the Daily Mails web site after an interview he originally gave to The Conversation about the myth busting campaign. He goes on to highlight four key areas that the Daily Mail readers comments fall into…
- Physios are not qualified to diagnose and mange back pain
- Doctors need to screen and scan all those with back pain before they start physio
- There is a lack empathy for back pain by those who havent had it
- Physios who advise those with back pain to exercise are trivialising the problem and saying its all in their heads
First I think its important that we recognise these issues and I think Chris has done a nice job in summarising them. However, I think it also should be recognised that this interview Chris gave that generated these negative comments about the myth busting campaign was done on his own, without the knowledge or approval of the CSP or the rest of the working group involved, and even before the campaign was officially launched. Why Chris decided to do this is beyond me, maybe eagerness, maybe self promotion, but I think he needs to accept that some of the negativity around this interview was of his own making and not just from the message in the campaign itself.
It was clear that this myth busting campaign to the public on a deeply personal and emotional topic like back pain would generate some kick back and ruffle a few feathers. Because of this the idea was for the campaign to be presented and promoted as a unified approach with a strategic launch that demonstrated to the public that these myth busters are not just the thoughts and ideas of one or a few physios, but rather as the profession as a whole. In my opinion Chris failed spectacularly at this with his premature and independent interview and personally this is why I think the negative reactions where so strong to his interview. No where did Chris mention these views where the work of the CSP working group, nor the vast majority of the physio profession as a whole, instead it appears that these are just his views, as an expert.
Now no one likes being spoken to or at by an ‘expert’, and no one likes to be told you’re doing it wrong… and again I think the wording of Chris’s interview doesn’t help to connect with the audience. Now of course this could be editorial licence by the media, I personally know they can turn and twist things around to make something you’ve said sound completely different, but in this interview Chris doesn’t demonstrate much understanding or empathy to the reader with back pain. For example in the first paragraph he talks about the cost and financial burden of back pain before mentioning the personal and emotional effects, and he even goes on to say “most people with back pain don’t manage it well…”. Now if I had back pain and I started to read that sentence I would be pissed off, so I can understand others being to.
However, aside from these issues I also think its important to point out the fact that challenging any deeply ingrained belief about anything is never going to be a simple walk in the park or a smooth ride. There will always be resistance, there will always be kick back, there will always be angst, rage, and some gnashing of teeth. This is normal human nature when anyone is confronted with different or opposing views and ideas, and it is nothing to be alarmed, deterred, or put off by.
But it does appear that this campaign and some of the negative reactions it has created has alarmed and deterred some physios, with some thinking we need to back off, or change our approach in how and when we question myths about back pain. I have even seen some physios using this negative feedback as a pathetic lame arsed excuse to justify how we should not rock the boat and how we should continue to do what we have always done.
This shit drives me crazy, nothing changes if nothing changes.
Physios need to understand and accept there will always be difficulties in challenging and confronting patients beliefs and expectations, especially around an emotional topic such as back pain. Lets face it back pain has been, and still is surrounded by decades of crappy treatments, rash promises of quick fixes, and shitty miracle cures. But just because its hard, just because its slow, just because its not readily or easily accepted by the public, it does not mean we should stop promoting the message of keep moving, hurt doesn’t mean harm, and you don’t need a scan for your low back pain. If we just give up at the first obstacle, if we just give patients what they want, then whats the point of us being an evidenced based profession?
I’ve said it before and I will say it again, the biggest dilemma with the physiotherapy profession as a whole is that most if not all things patients come to see us for can be managed easily and effectively with some simple advice and guidance and some small lifestyle and habit changes, yet perversely these are often the hardest things to address, accept, and affect, for both the patients and the physios.
Instead the easier option is to carry on with the back cracking, rib popping, pelvic thrusting, spine twisting, machine buzzing, needling stabbing, tape sticking, muscle rubbing, trigger pointing placebo treatments. Yes you could argue, and I’m sure some will, that there is some evidence for some benefits for all of these things, but so what!
Personally I think all of the above ‘treatments’ are nothing more than gimmicks, illusions, and distractions wasting time, resources and diverting attention away from the simple yet uncomfortable truth, that once it is clear that there is nothing serious as a cause of pain, then usually it will get better or it won’t regardless what we do! Yes that’s right, I said it will get better on its own, no rubs, no pokes, no cracks, no machines that go buzz buzz, just time, its called natural history, and physios don’t like to talk about it. Instead they feel an urge to do something, they feel the need to justify their existence, they feel the need to help, and this is admirable and I understand it, no one likes to see someone in pain, and if we could try to do something about it then why not?
Well maybe because you could be doing more harm than help. Maybe you are helping in the short term but hindering in long term. Maybe by rushing in and reducing a patients pain by a little bit for a short while you are not allowing them to find their own ways and means of coping, adapting and managing. Maybe if we didn’t help so quickly maybe patients would become more adaptable and tolerant to pain.
Sounds harsh doesn’t it, but its how I practice and manage all of my patients. Sure some patients don’t come back and I’m sure they go an find some other therapist who will rub and appease them, but that’s their choice and my failure for not connecting with the patient or explaining the process better. My goal and aim is to make every patient I see as reassured, as confident, and as in control of their own issues as quickly as I can. My job is to become redundant and surplus to the patients needs as quickly as possible. If I can do this in 1 visit or 10 it doesn’t matter, but the sooner the better.
This approach doesn’t sit well with many physios especially in the private sector, as often many use business reasoning over clinical reasoning. They feel threatened that if they tell a patient it will be alright and not to come back unless they need, they will loose money and run out of work, and everyone has bills to pay. And again I do understand this, but this is ridiculous thinking, just in case you haven’t heard back pain is a global epidemic and its growing, it is now the second highest cause of global disability, and there is no sign of it letting up soon.
To be frank I think modern healthcare as a whole is one of THE biggest reasons for the worsening rates of low back pain. The constant need to intervene and to reduce pain is why I think many people deal with back pain so poorly. Modern healthcare’s desire to immediately remove or reduce back pain, I believe reduces the populations exposure and tolerance to back pain. If more with back pain were educated and able to feel reassured and understand its ok, its safe, it doesn’t need treatment, it will get better, then I think we would finally start to see the cost and prevalence of back pain care go down.
Now of course I understand that there are many, many other socioeconomic factors for the growing rates of low back pain such as reducing general activity levels, increasing rates of obesity, and its not just as simple as telling patients with back pain to get on with it. Or is it? I do think we have to reflect and take a long hard and critical look at our roles as physiotherapists, and as a profession be better at getting the key messages across to patients more often, more consistently. I for one am extremely tired and frustrated of constantly trying to unpick fear inducing incorrect crapola out of my patients heads put in there by other some other healthcare professional.
So in summary I thought this myth busting campaign by the CSP was a good start in trying to change the public’s understanding about back pain, and I was extremely happy and honored to be involved and play a small part in its development and promotion. However I was disappointed at some reactions and comments after Chris’s editorial, and yes the negative comments were disappointing, but this is not surprising, nor the fault of the campaign, or the messages it contained. And this is most definitely not an excuse to continue to do what we’ve always done, or to stop trying to challenge and confront the many myths on back pain, amongst other things.
Long may the mythbusters continue!
As always thanks for reading
Adam
Adam,
Thanks once again for your honest, on point, straight forward, plain language analysis of the problem(s) at hand. It is reassuring to know there are others out there on the same wave length and not afraid to speak up about whatever the issue(s) might be, regardless of the criticism that might be received as a result. Only this kind of forward thinking and communication can create the stimulus for change that is so desperately needed within the profession…….. for the customer and for us.
One of my first items to address with LBP is to give it the proper classification for the Patient, once all the variables of that persons presentation have been considered of course. As a life long and active sportsman (initially Rugby and now endurance sports), back ‘ache’ has been present for most of my adult life. It is undoubtedly compounded by a very healthy appetite and fondness of social gatherings. I feel lucky to be able to recognise this for what it is: An ‘ache’ that will ease with movement and not ‘pain’ that is harmful or something that I need to be concerned about, allowing me to continue to do the things I love doing. I find this very helpful for me and the customer, if I can sell this lower category diagnosis and idea to a person who believes that they are suffering with NSLBP and if the treatment of daily mobility, flexibility and movement (in whatever form is preferred), which doesn’t need to be excessive is diligently being followed then I know I can confidently cut this person loose to look after themselves with a good chance that their ‘backache’ will never burden them or anyone else again.
Please continue to fight the good fight for all of us.
“Motion is Lotion”
Mike
Cheers Mike ?
Until there is more consensus between all of health care PT, GP, surgeon, chiros, osteos then general public will always have somewhere else to go to reinforce their poor beliefs.
With NHS privatisation I think it could possibly get worse with profits>patients mentality.
It does take more guts, conviction and sheer balls at times to talk somebody around from massage, needling etc in a private practice. The benefits though are clearly evident from a clinical outcome.
Great work though Adam (and co)
A good point, once we can start spreading the same message the better!
Adam,
This is one great text.
Changing brings diference, difrence brings progress and if progress was easy to achieve it would not be so hard acomplish …
Best regards
Branko
This mythbusting initiative needs to be adopted in Canada as well. Access to “free healthcare” has made it easy for the general public to fall into the trap that is negative reinforcement around LBP with our current medical model. It is a difficult thing to address, even to your own family, that people are glass figures and will break without needles or massage. It is reassuring to not only see other practitioners but whole countries who are beginning to address the real issues that drive LBP. As always thanks for the words of encouragement Adam!
*Aren’t glass figures! Autocorrect is a great tool for sending the wrong message.
Hi Adam
Long time no speak!
Interesting to hear both the BJSM piece by Chris and your take on it; both thought provoking. I have just read the Daily Mail comments for myself. Viewed in isolation, they can indeed appear bruising. However, as a physiotherapist working in a private marketplace specialising in treating patients in persistent pain, I would say they are fairly representative of the “backfire effect” I can see in clinical practice. Not enough health care professionals ( whether in the NHS or out of it) are changing their practice in the light of new evidence. Hardly surprising that the general public struggle with changing these views when many of the medical professionals advising them are not. As clinicians, we often face these “sticky beliefs” in patients and considering there were 29,000 views and only 125 comments (albeit most negative)I’m actually pretty impressed! Always the optimist, let’s hope the other 28,825 took something positive and helpful from it!
I agree that it is disappointing that Chris almost comes across as a “maverick” self confessed expert in this piece as in fact the myth busters campaign was highly evidenced and not only backed by our professional body the CSP but initiated by them. It was a huge leap forwards for the profession. This is why I put in so much of my own time as part not only of the working group behind it but also locally by promoting it within my patch alongside my own team and the very keen and knowledgeable local NHS community Physio team. Like you, I am passionate about getting the evidence across about back pain and how our modern progressive understanding of pain changes back pain treatment for the better for the benefit of patients. However, as a private practitioner, it has been really difficult for me to get public health messages such as those contained in the CSP back pain myth busters one across within my community as people are naturally cynical when a person with business interests such as myself comes out with them. That’s why having the professional body leading the way on this project was so key to its success. I spoke with key decision makers in the public health domain locally as a result of this campaign and felt maybe just maybe we were reaching a tipping point in getting engagement across sectors (as I say, always the optimist!).
Such a pity then that all that hard work and commitment from all involved in the campaign were not consulted or mentioned in the article. As physiotherapists, we are certainly not experts in dealing with the media nor do we understand yet how best to get these messages across. The CSP has experts in the media department that are there to help us. Let’s hope members learn from this and work together with both each other and by engaging the CSP team there to support them in future opportunities like this.
I personally believe it is pretty awesome that physiotherapy is leading the way in re-evaluating the evidence and adjusting the public messages accordingly. Ok, so we have a long way to go in getting the whole profession on board with these, let alone other medical professionals and the public. But it’s a start.
Keep up the good work ( but you do know my views about the swearing!)?
Helen Preston
Hi Helen
Thanks for your comments and insights and as a member on the working group and the subsequent work you did after to publicise and promote the campaign I’m sure you share my pride but also frustrations.
And you’re right I’m sure many took some positives from the daily mail article and let’s hope it started to sow the seeds.
And as for not liking my cussing and swearing, well that’s easy Helen, you just need to increase your exposure to it ?
All the best
Adam
I think our profession is too concerned about it’s academic leanings and likes to brush common sense to one side in case our role should appear more straight forward than it actually is our could be. As an example of this I saw a great tweet this week of a physio who had taped a badly bruised thigh had been K taped…4 days later..no bruising…what a surprise !…but of course it wasn’t resolved by time in the physios opinion… it was the K taping….aaaaaggggghhhhh !
Aaaaargh indeed ?
You make some very valid points Adam. Anyone who’s been in practice for awhile understands the 2 different paths to go with a treatment program: A) Start treating the patient with everything they ‘perceive’ to be treatments so they can say they are getting something, or B) Tell them that there’s no underlying serious pathology and to not worry about moving about. I prefer the latter, although there’s a chance the patient will go to someone else.
I think once all therapists, chiropractors and doctors are on the same page with respect to what information to provide in this situation, we’re always going to have different treatment protocols for the same patient. We’ve seen that in a few studies in the past when therapists and doctors can’t agree on the best treatment method for a specific condition. On top of that, most of the treatments recommended didn’t even follow appropriate guidelines.
I totally agree with you. However, I also find that in subacute and chronic cases, I’m also the guy that ends up doing the trigger points or the strengthening or Graston. And most of the time it works well. I find in those situations, problem solving and relying on past clinical experience plays a larger part in seeing success. But I won’t provide the same treatments for every patient. Although I agree with you on the acute stage, what’s your take in the subacute and chronic state? Do you feel clinicians are even more divided in taking the appropriate action, rely too much / too little on physical treatments or too much / too little on biopsychosocial issues, or rely too much on cookie cutter approaches?
Keep up the great work on the blog. Always refreshing to see different, and sometimes conflicting experiences to mine. That allows me to keep growing rather than stay stale in my ways.
I agree with your overall philosophy but wonder if there isn’t some middle ground. When I’m dealing with patients with LBP I begin with a lot of pain education and try and bring their anxiety level down. I’ll have them come in less times a week than other patients. But I find it’s extremely difficult to sell them on the idea that this is a common thing that will just go away and rather find it’s much easier to convince them over the course of a few visits as their symptoms decrease. I let them know that this is probably the issue running its course and not the few things that I’ve done and that, if anything, it’s the exercises they have done that have been the most beneficial. Perhaps you are better at conveying these ideas than I am but I find it takes a few sessions to get that point across. Thanks for the post and the work you do.
Totally agree Robbie, as I said to get patients to feel reassured, confident and independent to take control of their issues can take 1 or 10 sessions, each case in individual! Keep up the good work!
Hi Adam,
I don’t see what’s wrong with Chris McCarthy’s article.
I agree with the myth busters campaign and mostly agree with your rantings, but to single out Chris McCarthy’s article as a reason why Daily Mail readers have got the hump is ridiculous.
The complaints from the readers are concerned with the myth buster advice being rubbish (along with NHS treatment being rubbish). The myth buster advice is word for word what the CSP has written (except point 5).
If Chris McCarthy had written ‘Here is the advice from the CSP’ and then just written the 4 myth busters, the response from the readers would have been the same.
The problem is the lack of a clear and unified message from the ‘medical fraternity’ (as too many people have a vested interest, or otherwise, in passive treatments) and that people don’t want to take responsibility for their own health.
TTFN.
Honest John
Hi Honest John (by the way my nan always said don’t trust anyone who calls themselves honest)
Anyway I agree with all you say. I don’t blame Chris article per se for triggering angry daily mail readers to get on their keyboard high horses and yes if the article said it was from the physio profession there may have been similar kick back, but we don’t know that.
My main issue was the comments I started to see from other clinicians about the kick back and negative comments to the article, not so much the article itself.
And as you say and I state the lack of consensus and unified message about how to deal with these painful things is THE biggest hurdle! Until we all sing from the same hymn sheet patient aren’t going to know who to believe/trust
Cheers
Adam
Hello! first time poster here so be gentle with me! When I first saw the myth busters campaign I thought AT LAST!! a group of physios have rolled up there sleeves, knocked back a large swig of spirits (my choice would be gin but a cheeky Rum will do) and confidently stepped forward in to the big bad world of “but I need a scan!!!” and “It was like a man ripped open my back with a Sharpe knife and twisted it around!” And to be honest Im so not surprised the article got the response it did.
Physio has for to long been dogged down by hierarchy, juniors who must bow down to the “seniors” and the “seniors” who cant wait to revel in there newly found power of a band……6. Personally I think this is the reason why so much common sense has just disappeared from physio, physios can be judgmental and keen to revel in authority (obviously there are exemptions!!) and its all about who knows the most origins and insertions, whos been on the most courses, who has what experience and most importantly how am I going to let everybody know it!
Now don’t get me wrong having a good clinical knowledge of the basics is essential but so is simply listening, understanding and being honest, on a level with someone who comes to you for help. I find Adams post interesting as I have both been down the hands on approach and completely hands of approach and I personally feel that my best results have come from a mixed approach (heavily biased towards education and socialization). Anyways I shall stop there! And for my Jerry Springer and finally moment pain will always be here but I have always found it interesting that its the people who are generally happy with life and themselves and wear the biggest smiles tend to have the least pain (but they may also have a bit of KT tape showing above there corduroys)
Adam – I hope I can be apart of a myth busting campaign in Canada! I have wrangled with many of the points you discussed but believe more now than ever that we must put aside our trick and pony show and help patients with less intervention. We live in the world of quick fix and I would rather be a part of the solution than the problem. Thanks for sharing and inspiring me to be a better PT.