Do no harm! Do nothing!

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 over. Instead lets look at the other side of these treatments, lets look at the potential negative effects they could have.

The other side of 1%ers

The first thing to discuss is how big could the negative effects of these 1%ers be. Some assume that any potential negative effects of these treatment is in proportion to any potential positive effects. That a treatment that claims a 1% positive effect will only have a potential 1% negative effect.

This is dodgy reasoning. If we were to apply this logic to other treatments then some highly effective proven treatments should also have highly proven negative effects and we just dont see this. Simply put no one actually knows the size of the negative effects of these 1%ers is, its just assumed that if there are some they will be small.

However, there are some awkward and difficult questions we should be asking about the potential harmful and negative consequences of these treatments, and our constant attempts as therapists to reduce, recede or remove pain in our patients or athletes. And I’m not just talking about the physical risks but also the psychological risks, things such as…

  • Are we reinforcing negative beliefs and fears for some that pain is wrong or harmful by always looking to reduce or remove it?
  • Are we reducing the ability and resilience for some to tolerate future painful episodes by always looking to reduce or remove it?
  • Are we creating a downward spiral of avoidance from perfectly normal activities that create some pain and discomfort?

It may seem counter intuitive to many but we could be inadvertently and subconsciously making people LESS resilient and LESS robust to pain by constantly trying to reduce or remove it too soon, too quickly. It may seem harsh and tough to say this, but whats wrong with experiencing some pain from time to time?

Ouch!!!

Pain is a normal and natural consequence of many things, such as after a tough session of exercise, or even face planting a diving board. However pain usually tends to resolve with nothing more than time, and little intervention.

Sometimes pain needs to be endured.

We know that by reducing your exposure to something it can reduce your tolerance to it (think of alcohol as an example as Tim Gabbett describes here), is this any different for pain? Does constantly reducing your exposure to pain when you experience it lead to a reduction in your tolerance to it the next time you encounter it?

When a therapist attempts to reduce or remove pain does this mean it will now take less stimulus to trigger another experience of pain next time you train hard or have an injury? And then does it take more and more interventions to reduce or remove pain the next time round?

Double Ouch!!!

Does this constant reduction of pain after experiencing it lead to a lower tolerance to painful stimuli in the future (such as a kick in the nuts). But then perversely does this develop a higher tolerance to the methods aimed at reduce or remove pain? Would we actually be better off simply saying to our patients that pain is normal, its nothing to be alarmed or worried about, and that it will pass.

Would we be better therapists by letting our patients experience some pain after activity and injury to allow them to develop exposure, resistance and resilience to it the next time it occurs? Are we making people more fragile and less resiliant by constantly trying to reduce their pain with manual therapy, tape, machines or cupping? I ask myself these questions daily with all the patients I see. I ask myself am I actually doing more FOR this person by doing less TO them?

My decision is often yes!

Now the other thing I want to stress here is that doing nothing, isn’t really doing nothing! Doing nothing actually it involves doing a lot. And doing nothing doesn’t mean you know nothing!

Explaining and reassuring a patient or athlete about all of the above and why they are ultimately better off NOT having all these treatments is A LOT of work, a lot of hard work. In fact doing whats best for your patient usually involves doing more work than doing what your patient thinks is best for them.

Don’t believe me! Then try it!

Try and NOT do that 37th session of spinal manipulation on the middle aged sedentary patient with the lower back niggle that keeps coming back to see you on whenever they do a little activity. Try and NOT put that kinesio tape on the semi regular runner for the 144th time who keeps getting knee twinges when they run more than 15k. Try and NOT to whack cupping thingys on Phelps before he swims for his gold medal in the olympics. Try and do any of these things and then tell me that’s doing nothing!

So in summary, some questions for you to ponder. Is the inconvenient truth for us clinicians that it is far easier for us to appease our patients and athletes in pain or discomfort by offering and administering treatments like cupping or any of the 1%ers rather than taking the challenging, difficult, and seemingly harsh stance of ‘doing nothing’ and asking our patients to endure and continue on? Is the current pain epidemic we have in our modern society due to our over intervention and relentless desire to reduce pain too quickly?

As always, thanks for reading…

Adam

PS: if you want to hear from some of the best doer’s of nothing in professional elite sport (which actually is a bloody lot) then listen to Westy aka Paul Westwood @triathlonphysio and Joel Filliol @JoelFilliol on this months Physio Matters Podcast…. Its awesome!

 

19 thoughts on “Do no harm! Do nothing!

  1. Great post…. And the cupping thing is ridiculous, it surprises me that people still believe it can be of any benefit. Sadly Phelps has just become the ‘best’ advert for its continued use.

    I agree doing nothing can be v tough, having to explain pain physiology in layman’s terms is hard. As Einstein said ‘if you can’t explain it simply, you don’t understand it well enough”.

    Sadly the ongoing conflict of appeasing patients rather than treating them continues…. And I don’t see it ending anytime soon.

    As long as therapists are solely relied upon to justify their own practice then some will continue to abuse evidence to support questionable techniques. You can always find some dodgy, unreliable, error strewn and questionably funded ‘evidence’ to support any ludicrous technique.

    I can’t help but think the CSP needs to be a little more forthright on denouncing the more alternative stuff.

    Anyway… Keep shining the light into the darkness Adam.

    • Thanks Christopher, and agree more needs to be done by the professional and regulatory bodies to highlight this nonsense! And yes I can’t see the pandering to patients ending anytime soon, unfortunately!

      Keep fighting the good and noble fight

  2. Great article πŸ‘Œ

    unfortunately the ideas of doing nothing still look like crime for some physio or maybe the most of them .
    And here we again and again with the same pt. coming back every time after DC asking for the same tape or TENS or whatever give them an immediately pain relief.
    Even I started to use less and less passive treatment some of the pt. came to after having those treatment with other physio which make changeing there believe very difficult for me πŸ˜”πŸ˜”

  3. Great perspective. I think it’s too easy sometimes to “do something to” patients. And patients have been trained to expect something be done for them. I recently met a young man who had been off work for a year with low back pain. Test after test showed nothing serious was wrong. He finally started to feel better when he started to exercise. Then he had a slight setback and was apparently told to stop everything while they tried to figure out the problem. when I saw saw him, I spent time chatting with him about the findings and how exercise already was helping and encouraged him to get back exercising reassuring him that he would start to feel better again. Next time I saw him, he was emerging from another Physio office that were “treating” his low back pain. I’m not sure if it’s laziness, lack of knowledge or falling for the”customer knows best” line.

  4. Simply spot on and honest, Nice read! Treating patients that expect someTHING instead of ‘noTHING’ keeps being a challenge accepted. The number of patients that do see the light keeps me motivated to keep spreading the word.

  5. I like the cut of your jig Meaks. Since I stopped all that over testing and over diagnosing been able to help many more people, exactly what I wanted as a physio.

  6. Reblogged this on Neil Wise Physio and commented:
    I remember way back in my student days in an exam for in-hospital patient post-op an open gall bladder op & after assessing the client electing not to finish a treatment but electing to allow the patient to rest & review later in the day. I was quite nervous until I got my results ( very pleasing) but more relevant was an early lesson in sometimes the “best Rx” is not to treat! Great blog Adam!

  7. Great post Adam…this could also be extended to GPs who feel compelled to something…anything within the patient’s 7 minute slot….polluting bodies with pharmaceuticals when advice and reassurance are equally as potent and offer no harm.

  8. Adam your perspective and comments highlight the difference between salesman and therapist when considering value and patient centric physical therapy. Well done.

  9. Great article! As a new grad in private practice, I’m finding it very hard to navigate the pressure on me to do the 1%ers to keep clients and essentially get them back in again. Me and my other rookie Physio friends are all quite disappointed with the reality that a lot of our bosses will compromise evidence based practice to sell patients “whacky shit” and convince them to come back time after time.

  10. Brilliant stuff Adam, as usual.

    I work with young people day to day and I find myself dealing with all the bullshit ideas and preconceptions of Physio passed on from the parents to their offspring. Whilst I try to reason with the young person why I’m not using all the faddy, colourful, passive hocus-pocus, I then have to remotely unravel potentially years of poor reasoning with the parent. A challenge to say the least, leading to some interesting conversations with the family Physio whom they have been “going to for years, and who is really good.” This is then when they tell me they go to see them on a monthly basis for “maintenance” sessions.

    If we can get good education and sound reasoning to our youth populations, we might just start to turn the tide on he 1%’ers and create better educated and more resilient patients in the future.

  11. Hey Adam! great post! really enjoy your articles! Totally agree with you on the whole not treating people in certain circumstances! Any chance you found any studies into ‘not treating’ patients out of interest? or would the only option be to look at RCTs and use the control if it is a ‘no treatment’ group as a starter for finding some evidence about this ( i know this could cause some bias) πŸ™‚

    • Hi Rachel, there are a few studies that show no treatment is better than treatment. The most relivant to us would be corticosteriod injections and tendinopathy, a recent SR by Bill Vincinzino shows just this, worse due to injections that just wait and see

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