Ch, ch, ch, changes…

Creating a change in our patients pain and symptoms is really important. That goes without saying. Or does it? There is no doubt that patients come to see us wanting/expecting a change in their pain and symptoms. But how important is it for us to get these changes? Do we have to change things a little or a lot? Do we have to change things quickly, or not. And finally do changes in symptoms help us choose better treatments or predict a patients prognosis?

Well there are many therapists who claim the above and strongly advocate and promote the importance of achieving significant in session changes for our patients. For example Maitland and Mulligan and their mobilisations, McKenzie and his repeated movements, even Lewis and his shoulder symptom modification procedure, all advocate that the key to success is in finding significant in session changes for all our patients.


Then there are the myofascial releasers, spinal manipulators, dry needlers, K-tapers, machines that go buzz/buzz/bing who also advocate, promote, and bombard us with claims that getting quick changes in our patients symptoms helps them comply, adhere, and buy in to our other active treatments and 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.

As a young, eager, and rather annoying junior physio I was taught to always test-retest everything and anything with every patient I saw. I was told to get the patient to do something that was painful, or restricted, or difficult and then do ‘something’ to try and change it. This usually involved me pulling, poking, rubbing, or zapping the patient with something.

Now 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. So the patient feels good, you feel good, the world feels good, it really is a good feeling, and I was lead to believe this was how I should always work and 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, especially these gurus is that these sudden and significant in session changes don’t happen that often. In fact they happen 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 don’t tell you, they don’t admit that usually most patients will say after some poking and prodding… meh, nothings changed, its kinda the same, or even sometimes it now feels worse! This didn’t feel so good, this feels like I’m a failure!


But I kept plugging away over the years trying to create these in session changes in my patients getting told to keep practicing and I would get better at it. I didnt! 

However, over the years I came to realise that it also didnt really matter if I got some patients feeling better there and then, as those who I did get some in session changes with  and reduced their symptoms quickly didnt always get better, and those who I didnt get any changes with did improve over time just fine.

I also began to realise that all the techniques are unpredictable and 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 a load of bull shit and a lame excuse (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. 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.

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 widely spread, meaning we have little 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 counter 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.

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 from getting to the more important stuff of discussing and exploring ways and means to create long term changes and get them of the shitty quick fix healthcare merry-go-round.

Devolving

In my opinion we are 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 healthcare’s meddling and interfering with this shit, trying to reduce, correct, and avoid it 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 pushed 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 change 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 we need to create changes for our patients, but these don’t have to be the quick instant changes in pain 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 the patients attention away from the quick change and look to creating the long term changes.

As always, thanks for reading

Adam

 

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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