Closing the window of opportunity…

There are many sayings used in this profession. Some are good for patient education, some are good to help us remember things, and some are just a bit of fun. However, some are also misguided, misused, and misinterpreted. One of the most misguided phrases I hear being misused by many healthcare providers is “creating a window of opportunity” and I am going to try and explain why I think these windows need to be closed more often than opened.

The phrase ‘creating a window of opportunity’ is often used by physio’s to explain and justify why they ‘do’ things to a patient. Ask any physio why they are ‘doing’ something to patient, be that manual therapy, electrotherapy, sticking a needle into, or some tape onto a patient and most will tell you they are ‘opening a window of opportunity’ that allows a patient to move more comfortably, more often. Well that is only if they don’t tell you  some other crap about releasing or realigning something.

What’s wrong with that?

Many see no issue with this, but I do. I see it as an easy, convenient, and weak excuse that allows physios to continue to use many low value shitty interventions that have been found to be ineffective, and do little to enhance or gain any significant improvements in the long term, and are just NOT needed to improve outcomes  (ref, ref, ref, ref).

To put it bluntly, the window of opportunity is more for the therapists benefit rather than the patients.

Now before you go all nuts in the comments section (again) let me be clear that I am NOT saying you can never use these shitty modalities, nor am I trying to belittle our profession, or undermine its purpose, or target anyone or anything in particular blah blah blah. 

Rather I am just trying to highlight how we are quick to defend the ‘stuff’ we do with terms like ‘creating a window of opportunity‘ than actually face reality, and the evidence that shows the effects of these interventions and the windows they create are generally very small to non exisitent, and usually do not help in the grand scheme of things.

We need to start facing the facts and ask ourselves some difficult and awkward questions. For example are we using terms like ‘creating windows of opportunity’ as the easier option rather than admitting what we currently do doesn’t work? If we as a profession are to stand any chance of survival in modern healthcare we need to prove our worth but also admit when we don’t help and cut out the low value ineffective treatments. Have no doubt that there is a very real risk of the physiotherapy profession being relegated to the realms of ‘alternative medicine’ with the mystic healers, quacks, and other nut jobs with their energy crystals and hot stone crap unless we pull our fingers out of our ears, and our heads out of our asses and stop making excuses like we ‘create windows of opportunity’.

Other negatives

We also need to consider the other side of this window of opportunity. Lets consider that these small, unreliable, temporary windows of opportunity could also be creating more problems than they solve. Let’s consider that we are too busy focusing on short term solutions, to consider long term issues. Lets consider that these windows are a part of the reason why chronic musculoskeletal conditions are on the rise when many other healthcare conditions are on the decline (ref).

In my opinion a major reason for the growing chronic pain epidemic in our society is due to our constant and relentless desire to reduce it, remove it, or avoid all things that hurt. Just like modern society is becoming more antibiotic resistant due to our over consumption and over use of them, we are also becoming more pain intolerant due to our incessant desire to remove it. Pain at times is inevitable. Pain at times is essential. Pain at times is necessary, and we simply can not nor should we always look to remove or avoid it.

Most patients we see with pain simply need reassurance that nothing serious is wrong, that it will ease in time, and that they need to keep going. They don’t need pain killers, they don’t need any surgery, and they don’t need windows of opportunity creating. This is however isn’t the best business model, hence the reluctance for many to stop using it.

I ask you to consider what is wrong with asking some of our patients with pain to simply ‘grin and bear it’ for a while? What is wrong in advising some of our patients to continue to do something that hurts? Why do we always feel the need to try and find ways to reduce pain before they do an activity, exercise or task? Why do we assume that getting a patient to do something that hurts will make things worse, when we know it can actually do the opposite? (ref, ref, ref, ref)

Now before you all go and jump onto the logical fallacy band wagon that I know many of you like too, I am NOT saying we need to ask EVERYONE with pain to ALWAYS do things that hurt, so please take your false dichotomies for a long hard and painful running jump.

A crazy idea

Many will argue that there is nothing wrong with short term pain reduction using modalities as benign and low risk as manual therapy, electrotherapy, needles, or tape, especially in a world of over medicalisation and surgery.

I disagree

I believe that we as therapists are no different to our surgical or medical colleagues, and need to be scrutinised under the same microscope. We are very quick to chastise our surgical and medical colleagues of over treating, but we are JUST AS guilty of over treating, it’s only the tools and side effects that are different. Surgeons have their scalpels, doctors have their drugs, we have our needles and machines that go bing.

But here’s a crazy idea, how about we don’t always try to create windows of opportunity with tape, manual therapy, or machines that go bing. How about we don’t give our patients the impression that pain has to be reduced or removed before they do something. How about we don’t reinforce the belief that pain is harmful or detrimental. How about we don’t pander too our patients, wrapping them up in cotton wool and giving them the impression that they are delicate, fragile, or frail.

How about instead we start behaving like we aren’t scared of pain. How about we start acting like we don’t think we are going to break or harm our patients by asking them to do something that hurts them a bit, for a little while. How about we as therapists start showing patients that although pain is unpleasant, it ISN’T harmful, it CAN’T be avoided all the time, and sometimes it NEEDS to be confronted and endured to move forward.

Sounds a bit harsh and cruel doesn’t it! Well it’s not! It’s evidence based practice!

Craske’s paper on maximising exposure therapy here talks about just this, it discusses how we should be challenging some of our patients expectations more, without providing them with safety cues or windows of opportunity to create long lasting behavioural change. If you haven’t read this paper I strongly suggest you do, its a bit hard going in places and a whopping 14 pages long, but you wont regret it, it will challenge your practice and show how maximising exposure therapy can be extremely therapeutic and positive. If you want an easier option then go and listen to my fellow PT Podcast Network colleagues Cory and Sandy over on the Pain Science and Sensibility podcast who discuss it at length here.

Not so benign

Also many of the interventions used to create these so called windows of opportunity are not as harmless or benign as many think they are. Putting aside the real risks of adverse events from techniques such as spinal manipulation (refs) needle therapy’s (refs), or even cupping therapy (see picture below), there are the other not so obvious harmful effects of these ‘creating a window of opportunity‘ interventions. Things such as ‘creating a window of dependancy‘ and ‘creating a loss of self efficacy‘.

A clear adverse event after cupping therapy: source unknown

I personally have seen and heard over the years far too many patients telling me of the thousands upon thousands of pounds they have spent on all of these ‘window creating’ treatments, and still be no better off, with no better quality of life, with no better function, and no improvement towards their long term goals. Instead most have big holes in their bank balances, negative beliefs that they need these treatments for the rest of their lives, and a loss of hope of ever seeing anything change.

Even when I hear well meaning, evidence based therapists being fully explicit in explaining that these ‘window of opportunity‘ techniques are only to be used short periods, patients still get dependant on them. I have had patients of mine sheepishly admit that they have gone and seen other therapists to get a manipulation or session of dry needling whilst I am trying to ‘wean’ them off. It actually feels like at times like I am dealing with addicts, and these are intelligent, rationale, and reasonable people. This is also when I tend to hear therapists say ‘if I dont give it to them, someone else will‘ excuse. This is complete bull shit! When did two wrongs ever make a right.

Nothing wrong

Now I do realise that not everyone has a dependant personality or losses their self efficacy at the drop of a hat after a few sessions of manipulation, dry needling, or taping. Some patients do just want their pain taken down a notch or two, for a little while. This is when therapists come at me and say what the hell is wrong with ‘creating a window of opportunity‘ here then Meaks?

Well first of all, who says you can’t create this window without ‘doing’ something to a patient. Think top down before bottom up. Advice and education on its own as a pain reducing intervention and can be just as if not more effective as anyting else we do to patients. As the late great Louis Gifford used to say…

Effective reassurance is a bloody good pain killer

The other issue is that all these window creating treatments steal time from consultations in which we could be doing something more effective, and they all are highly unpredictable and highly unreliable, with neither the therapist, nor the patient having any idea of how much, or how long the effects will last for due to a host of variables and confounders.

This unreliability and variability leads to uncertainty and eventually mistrust for patients. I have seen this when I used to do spinal manipulations, dry needling, taping etc. I have seen patients get complete pain relief one session, to actually having more pain after the exact same treatment the following session, and before the ‘experts’ tell you that this is simply due to a lack of experience and skill, this is a another pile of utter bull shit as well.

So this is why I have emptied my tool box of these shitty techniques completely. I am not a fan of doing things to my patients that I have little to no control over, and even if I did, as I have already mentioned these effects are always short lasting, generally not needed, and take up too much of the time during consultations, time which I could be doing something far more productive with patients like maximising exposure or just getting them moving more.

So in summary, I hope I have demonstrated how we need to stop constantly looking to create small, unreliable, windows of opportunity to reduce or remove pain. I also hope I have highlighted that we don’t always need to reduce or remove pain BEFORE asking someone to do something, and that it may occur AFTER. I also hope I have shown the negative aspects of creating these so called windows of opportunity, and how they can promote fragility and fear.

So ask yourself, are you as a therapist too focused on making people feel nice in the short term to get them better in the long run.

Finally, I hope you will look at these windows of opportunity differently, and realise they do very little, except let in a bad draft, so please do me a favour and close that god damn window.

As always, thanks for reading

Adam

 

18 thoughts on “Closing the window of opportunity…

  1. New grad PT here. I’ve quickly figured out that so much of the manual therapy I was taught and the other established therapists were doing were not nearly as useful as I originally thought. The majority of my ‘manual’ treatments now are just finding creative ways to get the patient to move into what they perceive as painful ranges of motions. A lot of manual resistive exercises and even simple PROM while simply distracting the patient with light friendly conversation. They soon realize that they actually can move without pain or even if they do feel pain it’s not nearly as bad as they thought it would be.

    I don’t think you need to get all fancy with crazy technical sounding manual techniques. I find myself shaking my head when i see other therapists perform their fancy manual BS. The problem arises when the patient expects these techniques as it creates a false sense of high competence with that therapist when in reality it’s probably nothing more than active placebo.

    • Hi Scott thanks for the comments and I agree with most of what you say, especially the BS around ‘technical’ manual therapy! I guess you can use simple manual therapy and distraction to create a safety zone that can reduce pain, but this is still wrapping patients up in cotton wool and trying to be too helpful. The urge to do something is very strong for therapists, when actually they maybe doing more harm in the long run. As the Craske paper shows we can get great long lasting results by maximising exposure to things patients fear hate the most WITHOUT the safety cues etc.

      • It’s tough being a new grad. Especially when your ‘mentors’ are telling you ways to bias the VMO, use dry needling, cupping (lol), and insist on using muscle energy to correct rotated iliums. They have solid understandings of biomechanics yet I often question the clinical relevance of their observations and assessments.

        Do you have advice for new grads?

        • Try to work out when to nod along and keep your mouth shut and when to speak your mind and challenge things

          When you work that out let me know please as I still don’t have a clue and tend to ALWAYS put my foot in it!!!

          • I still have a lot to learn and a lot of the times I don’t know whether what my mentors are ‘teaching’ me is as clinically relevant as they think it is. It’s extremely frustrating to be taught things and to be expected to practice in a way that you don’t really agree with. I admit my understanding of biomechanics needs to improve as is probably the case with a lot of new grads. I disagree with my mentors who insist that PT is 100% about biomechanics.

            Thank you for your blog. I read it regularly and wish I had a fellow skeptic in my clinic I could follow and learn from.

  2. Good post Adam. I’ve always believed if you can re-establish normal movement the body will begin to behave normally…and have also cleared out the toolbox. I hadn’t seen the Louis Gifford quote before…I’ve wondered to what extent I’ve talked patients better over the years.

  3. I think the problem is that most physios are too bloody ‘nice’ for their own good! While I’m sure they have the best intentions, they often feel the need to ‘help’ (ie. interfere) in some way, without realising the harm they may be causing.

    A good read, and once again I find myself agreeing with many of your points. However, I can already hear the dismissive comments of my colleagues when I try to discuss it with them on Monday morning!

    • Haha… Good points Matt and I get those dismissive comments from my colleagues daily/hourly… makes my day seeing their eyes rolling in their heads but I can see things change as I keep wearing them down! Most have now stopped using ultrasound! It’s the small victories like this that keeps me going!

      • You’re lucky. My colleagues in one of the Trusts I work at still use ultrasound. And they insist acupuncture is great because they’ve “seen the results”! They look at me in a slightly pitying way when I patiently explain to them that it’s a load of old bollocks.

  4. Great minds think alike…. “If there is the slightest chance that a patient can be educated in any method that enables them to reduce their own pain and disability, using their own understanding and resources, they should receive that education. Every patient is entitled to education and every therapist should be obligated to provide it” Robin McKenzie – 1989 #Empowering #SelfManagement

  5. Great post Adam,
    I’m definitely guilty of opening windows, but considering I used to ‘fix’ people with manual therapy it’s a step in the right direction. Reading this and the references has challenged me and opened my eyes.
    Do you primarily take an education and movement/exercise approach with people?

  6. Hi adam
    another sensible, impassioned view on the crazy world that is physiotherapy. I have found myself questioning my own practice now for many years, hang on, that sounds wrong….I mean questioning what ive been taught, how to do things and looking at things through the eyes of evidence, application and outcomes with my patients.
    its a real shame the stimulus for change within our profession might well be service funding and fear of decommissioning other than good practice, in that as you rightly say, we are going to have to as a professional body of supposed clinical autonomous therapists, stop putting our fingers in our ears and keep doing stuff “cause ive seen it work, but I don’t know how it works”
    as part of a team striving to streamline service changes for an uptodate, evidence based MSK pathway I am continually exasperated as some staffs methods, use of time and resources and complete stubbornness at change. They just will not have it that passive therapies are at best, exactly that, passive, and there is just so much more you can do to get better, and more functional outcomes. Some peoples view on their autonomy seems to give them the view they can do what they like, irrespective of evidence and outcome. Quite extraordinary really.
    Then the same staff use the argument that we are only saying all this to save money, its a “numbers game” etc. Again quite extraordinary, yes, modern physio is a numbers game unfortunately but I see this change as a positive, to drive out unwanted passive nonsense and ensure patients are seen appropriately and this whole passive, nanny state we have developed for patients just stops, and we get a better message across to more people.
    keep up sending the message adam, I for one am with you.

    • Thanks Martin for the kind comments and sharing your experiences, they mimic mine and I’m sure many others. All I stress is that we ALL continue to challenge and question out dated practises to eventually create the chance we desire

      Cheers

      Adam

  7. Thank you Adam for this article.
    I will try to be as short as possible, becouse this topic is wide …

    I agree on the most of you have said, and I can see where is it coming from.
    In Serbia at this moment we have the trend of – supersonic physiotherapy … expencive machines will do everything … we all know how this ends, and who is there to try correct what is left … figuratively speeking.
    I believe that all physical therapists must be aware that the pain is subjective sympthom, subjective reaction to internal or external stimulus, and that as you say reasurance and education of patient can be much effective than any modality or pain killer.
    However, we also must be aware that tha pain affects not only range of motion and motor function, but mind and quality of life of every patient and that we have to help them ease it.

    So by my opinion there is no back an white. I use the modalities to help me achieve some of my goals, (reducing/promoting inflamation, reducting pain, promoting tisue elasticity, blood flow, reoxigenation…), but the key of rechabilitation is activation and use of present capabilties in order to acheve more capabilities and so on …

    To rely on modality to do all the work is wrong, but wise use of modalities can be helpefull …

    Best regards Adam and please keep up with what you are doing becouse I find it very usefull and thank you for that!

  8. Challenging post certainly. I’m a year into my career as a physio and have used manual techniques alongside the education/ exercise based therapy. Still learning loads about how to maximise movement based rehab. Definitely use electro therapy too often at current. Trying to teach myself more about exercise based rehab and how to progressively overload someone in order to gain adaptations so I don’t have that moment of panic when I see something I’ve not seen before and revert to the ultrasound/ laser in order to buy time while I research evidence based rehab (I know that sounds ridiculous but I’m trying to acknowledge my faults and get better at working on exercise based rehab)

    There’s one thing I’m not sure about though and that’s educating people on how much pain is appropriate. Can you push through too much pain? Is there a point when your body is trying to tell you something. I wondered if you had any thoughts on that or what you do to help people understand more about pain? Really appreciate your blog posts and always wanting to learn more from guys with more experience.

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