Ch, ch, ch, changes…

Creating a change in our patients symptoms is important. That goes without saying. Or does it? There is no doubt that most patients come to see us wanting a change in their pain, their disability, or their dysfunction. But how important is it for us to get these changes? Do we have to change things a lot, or just a little? Do we have to change things quickly, or slowly. Do in session changes help us choose treatments or predict a patients prognosis?

Well there are many therapists who strongly advocate and promote the importance of achieving significant in session changes for our patients, and that these changes help us predict patients prognosis and choose best treatments for them. For example Maitland and Mulligan and their mobilisations, McKenzie and his repeated movements, even Lewis and his shoulder symptom modification procedure, they all advocate the key to success is in finding significant quick in session changes for all our patients.


Then of course there are the gurus of our professions from the myofascial releasers, spinal manipulators, dry needlers, K-tapers, machines that go bing-ers who also advocate, promote, and bombard us with claims that getting quick instant changes in our patients symptoms helps them to comply, adhere, and buy in to our advise and other active treatments and again improves our outcomes and success rates.

I disagree

I don’t think we actually need to change things that much or that quickly for many of our patients to have successful outcomes, and as a young, eager, and rather annoying junior physio I annoyed many clinical educators and seniors who constantly told me to go and create these in session changes with all my patients. I was taught to always test-retest anything and everything with every patient. I was supposed to get the patient to do something that was painful, or restricted, or difficult. I would then do ‘something’ to try and change this, usually involving me pulling, poking, rubbing, or zapping the poor patient. Afterwards I would get my patient to retest that same thing that was painful, restricted, or difficult, and cross my fingers, toes and anything else I could and hope they told me it felt better.

And when it worked it was an awesome feeling. The patient thinks you are miracle worker, you feel great knowing you have made a difference to someone in pain and distress. The patient feels good, you feel good, the world feels good, it really is the best fucking feeling, and I was lead to believe this was how I should measure my success as a physio.

However, it didn’t take long before I began to feel disheartened and disillusioned because the uncomfortable truth that no one ever talks about is that these sudden significant in session changes don’t happen that often. In fact it happened very rarely. I would say that for every patient that got a successful in session change there were about 10 others that didn’t. This is what the gurus and teachers don’t tell you, they don’t admit that usually most patients will say after some poking and prodding… nothings changed, its kinda the same, or even sometimes it now feels worse! This didn’t feel so fucking good, this feels like I’m a fucking failure!


But I kept plugging away over the years trying to create these in session changes in my patients. However, over the years I came to learn and realise that all the techniques are unpredictable and all are unreliable, and when they did work they all vary in how much and how long the effects would last for. And before you go and say this is due to my lack of skill or experience in how I apply or do these things, I will say that’s bull shit (ref). And before you then go and say its because I don’t use them on the right patients, that’s also a load of crap (ref, ref). I will accept that some experience gained to develop comfortable handling and confident application of said poking and prodding may have helped a little, but this is NOT the only factor that determines success or not. I have seen many times with my own eyes that I can do the same technique, the same way on two different people with the same issue and get completely different results.

So over the years I have come to realise that these in session changes are not actually needed for me to get successful outcomes for my patients. For example, many of those patients who didn’t get an in session change would still get better, even the ones I occasionally made worse and were daft enough to come back, they also got better. And even the one’s who did get a significant in session change and thought I was a miracle worker, sometimes they wouldn’t get better, so all in all it didn’t really seem to matter if I created in session changes or not.

Now the evidence about the need for us to create in session changes to help guide treatments and predict successful outcomes over the course of time is limited. But there is some, mainly in low back pain (ref, ref, ref). However before you get too excited it is important to consider that this is by no means robust evidence. First these studies look at very short time periods and don’t compare against a control group of no treatment. Also the confidence intervals of the positive association of those with in session changes are hugely spread, meaning we can’t have any confidence in the power of the association, it may just be that those that get in sessions changes would get better regardless of what we did. And then there is evidence in shoulder pain that in session changes do not predict outcomes or help dictate treatment options (ref)

So although its can be nice to get quick significant in session changes for a patient and it may increase the chances of them improving sooner, they are by no means necessary or definitive. And once I stopped constantly trying to create these in session changes with my patients I began to realise that they were often only a distraction for me and the patient from getting to the more important stuff of discussing and exploring ways and means to create long term changes and get them of this shitty quick fix healthcare merry-go-round.

Devolving

In my opinion we are now living in a world of slowly dissolving self efficacy. We are a population slowly losing the ability to look after ourselves. We are a generation that fails to take any responsibility or control for our own issues. We are a species that has lost sight of what is hard, difficult, or challenging. In today’s society of quick fix, instant gratification, someone else’s fault, we look to blame others, hand over responsibility, and take the easy path. We are devolving, and in my opinion modern healthcare has a huge role in this catastrophe.

Ok modern healthcare and medicine has undoubtedly saved millions of lives as we understand and treat serious diseases and injuries better. I am not questioning this. But when it comes to the not so serious shit, the shit that just gets better, the shit that should not cause any major issues, for any significant time, the shit that can be painful, annoying, and frustrating, but wont kill you. Its healthcares meddling and interfering with this shit, constantly trying to reduce, correct, and avoid that has fucked us up as a species.

In my opinion, all of us who work in healthcare be that physios, docs, surgeons, etc simply need to get better at reassuring patients that nothing needs to be done. I often find myself as a physio at the bottom of the shit heap with patients that have been from pillar-to-post having tried this and that for their problem, and all it has done is made them more confused, more worried, more painful, when all that need to be said at the beginning is this is ok, nothing much to worry about, it will get better, keep moving. Simply put we all need to get better at convincing and educating most of the people we see that they don’t need that injection, that tablet, that massage, that tape or whatever your quick fix of choice is. Yes this takes longer to do. Yes this is harder to do. Yes this is an arse ache to do. But that’s no excuse to roll over and take the easy option.

If we as healthcare professionals are not prepared to take the harder path, then why should we expect our patients to do the same. We need to lead by example. We need to stop looking for the easy yet unpredictable, unreliable quick fix, and focus our efforts on the harder more stable, more reliable, more challenging long term changes.


As the late great David Bowie said…

Ch,ch, ch, changes… turn and face the strange,

Time may change me, but you cant trace time

Now I’m not entirely sure what the white duke is getting at here, and i’m not sure it fits with my closing thoughts but it only seems fitting to finish with his lyrics seeing as I used his song title for this blog.

So in summary yes we need to create changes for our patients, but these don’t have to be the quick instant changes that many advocate. I don’t care if a patient leaves a session with me feeling the same or even worse. All I care about is does the patient feel safe, reassured, confident and in control of their own ability to get through this situation. In my opinion we need to shift our, and our patients attention away from the quick fix and look to focus on long term changes.

As always, thanks for reading

Adam

PS: apologies for the earlier email sent a few days ago in error… I pressed the publish rather than save button as I was making a draft of this post. Doh!

 

13 thoughts on “Ch, ch, ch, changes…

  1. Interesting blog, and I agree that we do as a profession, default to all those techniques and adjuncts that we have picked up down the years. We have unfortunately made our beds and created a level of expectation from our clients. We need to all be proactive in chipping away at this culture – promoting self efficacy and continued activity. It’s a constant battle though against the belief that something can be “put back in place” or “released”. If I stick to my guns, there will always be another Physio, Osteo, Chiro etc who will be willing to give them what they want…. so frustrating!

    • I definitely feel your frustration! The amount of times I’m met with blank stares when I attempt to educate that I’m unlikely to quickly fix their pain, or in chronic cases make it go away completely. Setting realistic expectations is so difficult when, as you said, there is always another practitioner who has jumped on the latest fad and is promising the world relying on exquisite placebo theatre to provide a window of relief.

  2. Hi Adam, as Louis Gifford wrote, changes in patients symptoms may be more likely due to changes in processing rather than tissue changes. I think it’s fair to say that he too believed modern humans lack some toughness. Thanks for your blogs and podcasts.

  3. Would you agree that it is acceptable to use short term changes as a way to buy into long term strategies? A huge problem is that if I say “short term changes don’t matter” they will just run off to someone who will put their spine “in”. We all know a little poke makes you feel better and a few reps appears to make you stronger. Why not practice a little “magic” if we are honestly aiming for the long game?

    Is the slope just too slippery to play these games? Or is it a worthwhile risk?

    • As I state in the blog, I don’t think or say short term changes don’t matter, they do for some. The issue is what about the ones who don’t get short term changes, are these destined to fail or not worth treating?

      Also what about those who do get short term changes and fail to engage or focus on log term strategies because all they want and see are short term fixes?

      And finally are short term fixes and changes simply making us all less tolerate and focused on long term issues, in my opinion the answer is yes!

  4. Hi Adam. Nice blog post. Agree with your thoughts. You delivered some short term evidence in the low back. Here is longitudinal study (Garrison, 2010) in the shoulder and it does not show any predictive value.

    Best regards Kenneth

    Garrison.2010. Between-session changes predict overall perception of improvement but not functional improvement in patients with shoulder impingement syndrome seen for physical therapy: An observational study

  5. “We are devolving, and in my opinion modern healthcare has a huge role in this catastrophe.”
    So true; we are living and working in the world of the ‘worried well’. It seems we need to focus more on changing belief not necessarily symptoms.
    Once again, bang on. Cheers.

  6. Thanks Adam for this I get a lot of hate for saying the truth back home but I guess I will keep saying it until it hits home . People need to do stuff our ancestors did not the archaic ideologies but moving engaging themselves in doing what they are supposed to be doing.

  7. Liberating post. Out of curiosity, how did you handle patient expectations of a “quick fix” when you moved away from focusing on in-session changes? Is there naturally an initial hit in patient returns and buy in?

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