Less is More… More or Less

Have you ever felt you’re in that Bill Murray film ‘Groundhog Day’ waking up each morning doing the same things, saying the same things, having the same discussions. I do, a lot. As you know I often question and challenge the effectiveness and usefulness of many things us physios do, and I often take the position that doing less is more. That is the adding of passive treatments or adjuncts to the core principles of education and exercise offers little benefit. This regularly upsets people and so off we go on another ‘Groundhog day’ debate like I have many times before.

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Now I recently had such a conversation with my good mate Tom Goom after I posted a comment on twitter about how I am seeing more and more people moaning about how they think manual therapy is getting a hard time and a bad reputation, and how I think this is a good thing and how I think the hype and crap that surrounds manual therapy needs to be questioned more often, more robustly, not less.

However, Tom 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, I should be equally critical of these things, and I think I am. For example, I am well aware that there is little ‘robust’ evidence for anything we do as physios. I am well aware and often mention that things get better regardless if we rub them, poke them, move them, exercise them, talk to them, things often just get better regardless (ref). This is called natural history and its physios dirty little secret that is never talked about, and when it is, it again upsets some people.

Nothing changed!

Now as usual it wasn’t long before a few others joined in on the discussion me and Tom where having, most looking to defend the use of manual therapy, and as usual some soon 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 on, 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 achieved or 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 thr point at issue, I am quite comfortable doing very ‘little’ with most of my patients, preferring to stick with the core principles of giving good advice and education, encouraging moment and then loading it.

My simplistic approach has been neatly visualised on the right here by Tom…

Its so clean, simple and beautiful it makes me weep just looking at it…

However this simplistic approach is not really doing ‘little’ in fact it is a hell of a lot harder than it looks, doing little actually involves a lot. Simple is hard. 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 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 or lazy!

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 never use them as often accused. As a physio with many post graduate manual therapy courses under my belt I do occasionally use some manual therapy. Also as an extended scope practitioner trained in diagnostic ultrasound and injection therapies, I do occasionally inject under ultrasound guidance using corticosteroid and/or local anaesthetic in certain circumstances and for certain conditions.

I do understand that at times strong patient expectations are to be respected. When a patient believes something will work, it will work (ref). But this doesn’t mean I will just do what a patient wants or expects, sometimes a satisfied patient isn’t a healthy patient (ref).

Screen Shot 2016-09-03 at 22.07.20 However, not many patients die from a bit of massage or a corticosteroid injection, and so if there is no clear risk or detriment to a patient, I will use an injection or some manual therapy from time to time if a patients expectations are high. But just because I use these techniques occasionally doesn’t stop me questioning or challenging the effectiveness or usefulness of them, 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?

So lets first look at corticosteroid injections which was brought up in this recent debate by some. Well these 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. Well there appears to be no benefit for for spinal manipulation in chronic low back pain (ref) or acute low back pain over sham or inert interventions as an adjunct (ref). It appears there is no benefit of one type of manual therapy over another (ref). And adding manual therapy to exercises doesn’t always 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).

Massages-Serenity

In my opinion manual therapy may actually be the reason 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 around 3 or 4 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 robuster, 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

15 thoughts on “Less is More… More or Less

  1. Thanks for sharing! Far more skills required to rewire a patients CNS and undo the misplaced beliefs they’ve held onto for donkeys years.

  2. I think the last paragraph really nails this subject Adam, every professional out there needs to ask themselves what their core values and duties are.
    I’ve been watching these conversations, and occasionally joining in, on twitter with great interest.
    Its extraordinary that these things still go on, let alone that we are debating them. Although as you say, its great to debate, engage and these platforms give us so much more opportunity to share views.
    I know for a fact, the less I touch folk, the better they get. And I like you, i have umpteen manual therapy courses under my belt, been around a while, have been trained by “gurus” and spent a lot of time and money listening and learning. Ive implemented all ive learnt, used techniques, audited, reflected, passed my knowledge and experiences on, and I still don’t understand any of it or what it professes to achieve!!!!

    For all the reasons you’ve mentioned, and even when it stares people in the face, be it evidence, fact, or just common bleeding sense, some choose to ignore it. I cant explain why. maybe its the whole “I must do something to my patient” therapist, I just don’t know.
    All I know is what I can control and how I can utilise my limited time with patients, and try to reflect given what evidence is available to us all, and how my patients respond to my advise/help.

    I feel the tide is turning, as a science based profession we simply cannot just keep applying all these things because we always have, its madness!!!!!!!!!

    Keep up shouting from the rooftops!

  3. “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 promote the benefits of a healthy and active lifestyle. I became a physio to help others who are struggling with this due to pain or injury. I became a physio to get people moving more, to get them stronger, robuster, more resilient.”

    You have summed up my entire career in this statement. Amazing how physio school is what made me think I wanted/should be doing more poking, prodding, pulling and all kinds of external things. After 7 years of practice, like yourself I find myself touching less and educating more. I used to think I was less of a physio before I found your posts because I did “less” than my colleagues. Keep up the great work, love your stuff.

  4. As always, another excellent post. I regularly find myself using some of your phrases to better articulate aspects of patient education.

    Much appreciated

  5. Adam, Enjoy the posts as always. Love the references too. Just curious when you went from quaizi buying into MT to “this is all rubbish”. Was there a specific moment, or something gradual?

    Anyway mine happened when choosing my first continuing ED course. Having never taken one because I was in school I kept hearing about ART and how it helped everyone out and was much better than chiro treatments. I heard “it really solved the problem”. I then looked into the course figuring it was a one day, possibly one weekend deal, much to my dismay it was 1,000+ for Upper extremity certification and there were multiple certifications.

    Having watched a few Scientology documentaries in my time I knew what this was all about. Needless to say I am clear, Thetan free, and ART certified.

  6. “I am well aware that there is little robust evidence of anything we do, and that things get better NO matter if we rub them, move them, talk to them, or do nothing to them, things often get better regardless”

    As a new grad PT, it is this sentence that really has discouraged me so early into my career. The issue is, I totally agree with that statement. It has left me wondering many times over, what is the point of all of this? Am I really helping? Are we skilled or not? Sure, I can get my patient stronger and maybe they feel better along the way. Maybe it helps, maybe it doesn’t. I know my “manual therapy” isn’t really doing anything besides maybe non specific effects. Exercise is great but you don’t need a therapist with 7 years of schooling to get you to exercise.

    It has left me thinking; we really have less control with our patient outcomes than we think. If there isn’t a lot of evidence for a lot of what we do then we’re left with therapeutic alliance and non specific effects. Therapeutic alliance and non specific effects are great but do we need 3 years of schooling and a doctorate degree for that? I don’t think we do.

    • Hi Scott

      I agree the thought of natural history and regression to the mean for patients and their injuries can be quite down heartening.

      But don’t let it. See the positives that we are hear to help guide and facilitate people through this, and make them aware of it. This is what takes skill, being confident and reassuring and interacting with those who are in pain, scared and fearing the worst. We have a very worthwhile and important role and do make a difference in people’s lives because of this. This is what gets me out of bed in the morning and wanting to be a better Physio everyday.

      We are not healers, we don’t fix things, we are guides and restorers of confidence!

      Enjoy your career

      Regards

      Adam

    • I agree Scott. As a physio of 9 years I can take this statement

      “I never became a physio to rub or poke people. I never became a physio to stick needles into or tape onto people”.

      and say the exact opposite. That is EXACTLY why I became a physio. I wanted quick fixes. I wanted to make changes. I wanted to feel like there was a point to my career, and that I was good at something. And as I go on in my career and realise more and more how little that stuff does I hate my job a little more. If I’d wanted to be a psychologist I would have trained to be one. If I wanted to be a teacher I would have trained to be one. Don’t get me wrong, I love the teaching element of my job. I just didn’t think that’s all there was. The exercise prescription? Sure, love that too but if I wanted to be a fitness instructor…

      Well you see my point.

      I agree Scott. And Adam. And it’s just depressing.

  7. Hi Adam, congrats on this superb text! I agree with most of it. 🙂

    One thing, however, comes to my mind. Relating manual therapy, I tend to go the other way. Not the extreme other way, but I think, based on evidence, that it has effects on treating people, specially the back.

    You mention the cochrane revision of acute low back pain (https://www.ncbi.nlm.nih.gov/pubmed/23169072) and, I understand that when measuring benefit, in 4 weeks after it started, usually there will be no difference between those who actually receive any form of manual therapy, and those who didn’t. First of all, from my experience, we can accelerate that process with manual therapy, spécifically talking, with manipulation. There’s also evidence to support it (the mentioned review doesnt differentiate between oscilatory mobilizations and high velocity low amp thrusts – and that might be an important thing).

    The evidence to support HVLA in acute low back pain:
    SCHNEIDER et al (PEDRO 8): https://search.pedro.org.au/search-results/record-detail/42126
    VON HEYMAN et al (PEDRO 7): https://search.pedro.org.au/search-results/record-detail/35351

    On chronic low back pain, HVLA seems to add to exercise:
    AURE et al (2003): https://search.pedro.org.au/search-results/record-detail/4623
    MOHSENI BANDPEY et al: https://search.pedro.org.au/search-results/record-detail/15288
    BALTHAZARD et al (2012): https://www.ncbi.nlm.nih.gov/pubmed/22925609

    On low back pain there are others, but they sometimes mix acute and chronic patients.

    Regarding neck pain, I also think we can have very positive effects with manipulation:
    PUENTEDURA et al (2011): https://www.ncbi.nlm.nih.gov/pubmed/21335931 (cervical thrust > thoracic thrust);
    MASARACHIO et al (2013) thoracic manip adds to exercise): https://www.ncbi.nlm.nih.gov/pubmed/23221367
    CLELAND et al (2005): https://www.ncbi.nlm.nih.gov/pubmed/15922233
    LAU et al (2008): https://www.ncbi.nlm.nih.gov/pubmed/20813577
    CLELAND et al (2010): https://www.ncbi.nlm.nih.gov/pubmed/20634268

    Well, that’s where (and why) I disagree regarding the topic of manual therapy.

    Once again, thanks for your superb article.

    Cheers.

    Claudio

  8. Hi Adam, I’m trying to ascertain the utility of payment in the Physiotherapy realm. I agree completely that Physios need to do the simple things well before anything else.
    Do you think paying for Physiotherapy is a good or bad thing? For outcomes? And what about the impact on the profession as a whole? Does paying for the good standard specific and important advice propagate the cycle of dependency for society?

    • I think that depends on a number of factors, payment needs to reflect level of knowledge and skills, and consultation fees for physio are so varied across the country that it’s impossible to ascertain a reasonable average!

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