Low tolerance…

WARNING: you may have a low tolerance to the views within this blog! Read on at your own discretion!

We all have different tolerance to different things, such as how long we can concentrate, or exercise, or put up with some people, and this can vary for many reasons. I recognise I have a very low tolerance for many things in life, things such as idiots who wear those stupid toe/finger shoes, twats with man buns, or anything with avocado in it. I also have a low tolerance for those who slag others off behind their backs, and the many other wassocks in our profession who talk complete and utter bull shit.

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Anyway, as I was saying our tolerance to things both physically and psychologically is based on many things such as our experience, previous exposure, and the environment. For example, some people can tolerate exercise more than others simply because they do more of it. Some people can tolerate certain stresses in life due to previous experiences with them. And some people can tolerate others views and opinions more due to being taught patience and respect by their parents and teachers from an early age.

However, it is becoming clear that, in general, human beings are becoming less tolerant to everything. Many are less tolerant of things like food, textiles, medications, and other environmental factors. Many are less tolerant of change, diversity and difference, and many are less tolerant of difficulty or discomfort.

Most of us who live in the developed world now live a life of convenience and comfort. A world where we have ample access to food, water, shelter, and wifi. A world where you have technology and gadgets to make your life easier and effortless. A world where you can buy a device to put your socks on in the morning, or a duvet that makes your bed, or a machine that opens your jars. We don’t even have to go to the supermarket anymore to get our jars or lift them off the shelves and carry them in a basket a few hundred yards.

We are living in a world where effort or exertion has mostly been removed, where any struggle or strain is considered unnecessary and often avoided. Now, this lack of hardship and difficulty clearly has many positives, I for one am not complaining about my wifi, my central heating, or even my online grocery deliveries that I enjoy. But I do think the sheer amount of convenience and ease we have in our lives today has many drawbacks that most are not aware of or appreciate.

To put this as bluntly as I can we have lost sight and recognition of what is tough, hard, or inconvenient. What many of us think as difficult these days simply is not. Being without wifi, missing a meal, having to walk around a supermarket, are simply not serious challenges yet our modern lifestyles and environments and lack of exposure to these tasks have made them appear so.

when-people-complain-my-life-is-so-hard

And this is no different for pain. Having a sore knee, an irritable shoulder, or some low back pain with no history of trauma or unusual symptoms is, in my opinion, not a medical emergency or even a condition that needs to be treated. Simply put things hurt from time to time due to many reasons, the key point is they are not serious and they have a favourable natural history getting better usually with nothing more than time, but we have lost sight of this.

If we were to look back just 100, 50 or even 20 years you will see that most people with a sore knee, an irritable shoulder, or some back pain wouldn’t immediately seek medical attention or treatment. Now this may be due to lack of access to medical services was different back then, but I often ask myself when I have some pain from time to time, what would my grandad do with this… and most of the time it would be to just crack on!

I see day in day out how our species and society has become less tolerant to things that hurt. I see day in day out many people with some pain, an ache, or a niggle that clearly is not serious, life-threatening, or disabling, that clearly has a favourable natural history of resolving on its own with time alone. It is these things that as a physio I don’t treat.

Well, when I say I don’t treat, I actually mean I do. When I have listened to the patient’s history and concerns about their pain, done my examination and excluded as best as I can any serious issues, I will give patients some simple clear advice and reassurance that they have nothing to be worried about, that this issue will resolve in time and doesn’t need any further treatment or investigations. I will answer any questions or concerns they may have and may give some further advice about modifying some of their activities for a little while to ease or help natural history along, but mostly I tend to advise most that they should continue on as normally as they can. However, in this world of low tolerance, many people don’t like to hear or accept this, both patients and healthcare professionals.

Many think that being in any pain or discomfort is not acceptable and that it should be reduced or eliminated immediately. I disagree. I think many things that hurt from time to time need to be tolerated and endured more. I believe that by reducing and removing pain too soon, too quickly, too unnecessarily it is contributing to us as a species becoming less tolerant and resilient to things that hurt.

pain-meme

Many think living pain-free is an automatic right. It’s not. It’s a privilege that has to be earned with hard work, self-control, and some discipline. If you want your body to look after you, you need to look after it. Many non-traumatic musculoskeletal conditions we see are often the consequence of our modern easy convenient lives. Other times its just due to things like backs, knees, shoulders hurt from time to time for no obvious reason. Regardless, of why things hurt from time to time the key point is often nothing needs to be done other than reassuring people there is nothing to worry about, they will not damage or harm themselves if they continue on, and they should try to carry on as normally as possible and things will improve.

However, as much as patients don’t like hearing this, healthcare professionals don’t like doing this. Many healthcare professionals simply don’t like or feel comfortable telling people in pain and discomfort that its normal and nothing to worry about, and many healthcare professionals do not like NOT treating people for either financial or egotistical reasons. Personally, I think many musculoskeletal conditions are way over treated with healthcare professionals pandering to patients while natural history gets them better and makes them look good.

Now, this is not just me being scathing, cold, uncaring, or discompassionate, this is me being open, honest, and frustrated at a system and society that I think is going the wrong way and screwing things up royally when it comes to non-traumatic musculoskeletal pains. Healthcare has undoubtedly helped humanity hugely by reducing disease and pathology and increasing our lifespans, but healthcare also has and continues to have, a huge role in making our society less resilient and less tolerant to pain due to over-diagnosis and over-treatment of it.

This needs to change. Quickly.

If you look at the global burden of disease studies you can see that low back pain now consistently causes more disability and costs more than any other medical condition across the world, and this is despite advances in so-called pain management. Simply put what healthcare is doing for musculoskeletal pains just isn’t working and something needs to change. Personally, I think this needs to start with more healthcare professionals recognising that they over treat pain and many patients recognising that pain is inevitable, suffering it is optional.

In summary, non-traumatic musculoskeletal pains need to be tolerated and endured more and to do this healthcare professionals need to be better at confidently and compassionately reassuring patients that no treatment is often the best treatment.

As always thanks for reading

Adam

32 thoughts on “Low tolerance…

  1. “Personally, I think this needs to start with more healthcare professionals recognising that they over treat pain and many patients recognising that pain is inevitable, suffering is optional.” Adam, I think many people experiencing pain would not agree with you that their suffering is an “option”.

    • Hi John, sorry but I have to disagree, as someone who has experienced pain many many times for both short and long durations I can confidently say that mindset determines if you decide to suffer with it or not… Cheers Adam

      • Love this post, but I wonder if mindset isn’t the correct way to think about it because it implies it can be something so easy to change. I love the more philosophical side of things, because it ultimately informs how we think and thus approach health care. But if someone not only sees the world, but has shaped their entire life, meaning and defined their happiness based on a certain philosophy that doesn’t promote change or consideration of other viewpoints, their ‘mindset’ could be difficult to change.

        I see a lot of crossover with how we view happiness. Vox has a great article with researcher Carl Cederstrom that details the shift in philosophy, that I think correlates well with ultimately this change in ‘mindset’. That now we define our happiness as an individualistic pursuit based upon self actualization and improvement, which ends in ultimately, happiness as a right, not a privilege. Therefore, if happiness is seen a right, it can be easy to see how people define pain, an unpleasant sensation that can also limit our capabilities and ultimately what drives our sense of self and happiness, as a negative entity and ultimately exactly what you see and written about here Adam.

        https://www.vox.com/science-and-health/2018/9/4/17759590/happiness-fantasy-capitalism-culture-carl-cederstrom

        The addition to this is now we have technology that also drives us to skim read which ultimately affects our ability to read, comprehend and process new information and thus respond well when presented with new information, we’ve created the perfect storm.

        https://www.theguardian.com/commentisfree/2018/aug/25/skim-reading-new-normal-maryanne-wolf

      • Totally agree Adam I run a functional restoration program for people who are living with chronic pain for which physiotherapy has not helped. Just yesterday I had a patient tell me that although his pain remained at the same level he felt 90% improvement following treatment.

        The course is very much about education. We discuss pain mechanisms, body repair processes, pacing, lifestyle changes, psychological perception of pain, exercise benefits etc. Along with the education we run a gym session in the afternoon for good honest hard work and exercise.

        Now going back to this gentleman he has a very heavy manual job that he is now completing without issue. His words to me were that his pain was now a “background issue” it was still there but it didn’t bother him because he chose to focus on improvements such has improved flexibility, improved strength and endurance and a generally healthier lifestyle.

        Through reassurance, education and exercise this patient improved his quality of life and reduced his suffering without his pain changing at all.

        Now the likelihood is within 6 months of implementation of this way of thinking and living the patient will be pain free. Contrast this with a patient who is coddled and overdiagnosed that develops an external locus of control and makes no meaningful changes to their life. Now that is the type of patient that will report years of pain with no improvement despite receiving a lot of ‘treatment”.

    • Suffering is definitely optional. That’s the difference between the paraplegic who find gainful employment and continues on with their life and the “fibromyalgia” patient who goes on permanent disability/welfare and jumps from one health care provider to another trying to find the “miracle cure”.

      Same with at fault drivers vs. not at fault drivers when it comes to MVA’s. Majority of “chronic whiplash” patients are not at fault drivers while the at fault drivers just carry on with their lives.

      . Sullivan MJ, Adams H, Martel MO, Scott W, Wideman T. Catastrophizing and
      perceived injustice: risk factors for the transition to chronicity after whiplash injury.
      Spine (Phila Pa 1976). 2011 Dec 1;36(25 Suppl):S244-9

    • I am going to chime in here because this is an important opportunity for developing a sense of awareness that seems nearly absent in the formal orthodoxy promoted by PT. Adam, you are certainly entitled to your opinion, afterall this is your blog. On the issue of “suffering” and what constitutes this subjective experience, it is the same argument I hear when “pain” is substituted. The abysmal appreciation by biomechanists (most PTs) of psychological foundations of Self, personality, beliefs, and mental illness etc., prevents a more effective application of therapies. Just because you claim that you have experience in pain does not generalize beyond your shores; it is irrelevant to what suffering feels like for others in pain, whether physical or psychological. Few clinical psychologists would agree that one should just think positive thoughts and that would dispel the suffering of depression, for example. Its not about you. Its about the person suffering.

    • Einstein – I fear the day technology will surpass our human interaction. The world will have a generation of idiots!

      Too much crap information easily available and too much good information stifled. Keep spreading the good word sir.

  2. Completely agree. As a physio working in australia i find the biggest barrier to this is financial. Musc physio in australia is almost completely in the private sector and i cant find a boss who wants to pay me to effectively educate and reassure people they arent broken. Very frustrating as this is what is needed with a majority of patients i see

  3. Hi Adam,

    Thanks for continuing to promote your practical and common sense approach to pain management which empowers our patients and improves short and long term outcomes and which for those of us who use it is a no-brain option ! However, as common sense sometimes may not always be that common is still very noticeable how many physios (independent of age or experience) struggle with trusting exercise based rehab and still feel the need to over assess/treat or deliver manual techniques in order I think to feel like they have “fixed” the patient. Could it be insecurity on their part ? Or maybe the training pathway embeds in them the biomedical approach ? On a positive note I also believe that with the persistence of physios who use the active approach to rehab instead of passive alternatives that as we empower and educate our patients they may well become the channel through which the message flows to the wider population.

    Finally, keep up your great work as I think it is making a huge difference to our profession.

    Philip Phelan Physiotherapist Dublin

    Sent from my iPhone

    >

  4. “It is difficult to get a man to understand something, when his salary depends on his not understanding it.”

    Upton Sinclair

    Until the healthcare profession is not reimbursed for treating/overtreating nothing will change. I firmly believe if there were a billable code for an exorcism we would have continuing education , certifications, and in clinic seance’s.

  5. Thanks Adam, a good read. The world has gone totally insane. It’s all about the money, a fraction of the care is about efficacy, it is a complex interwoven hairy problem. Just off to my seance, Jane

  6. “Many think living pain-free is an automatic right. It’s not. It’s a privilege that has to be earned with hard work, self-control, and some discipline. If you want your body to look after you, you need to look after it. ”

    PREACH!!! 😂🤣 SO. VERY. TRUE.
    Self care, self care. 😊

  7. I agree that we frequently overtreat pain. A motivated patient will generally get better regardless of what the physician does.

    “Medicine is the art of entertaining the patient while nature cures the disease.” -Voltaire

  8. Adam, your original post, and the comments of those who agree with you, support my view that health care professionals are inadvertently contributing to the stigma borne by those who experience persistent pain without discernible ongoing nociception.

    • I am unsure as to how or why you think my views here are contributing to the stigma of those in pain? I recognise only to well that many people in pain are treated terribly by both the modern health care system and many of those that work in it, I see it day in day out and its getting worse. I am actually trying to help change this by highlighting how society, media, technology, education is adding to the problem not helping it. I feel you have misinterpreted my point John.

      • Adam, have you considered that chronic pain sufferers may already be feeling inadequate because they cannot measure up to their own and/or their societies’ expectations? Feelings of shame, isolation and self-loathing can be their lot in life. I cannot agree with you that such suffering is “optional”.

        • Yes John, I have and I see it in people daily. However, my job is to turn that around and try and help them see how they can continue to function with pain, how pain shouldn’t define them or stop them doing want they want to do, and how suffering it is a choice.

            • John, unless pain is being inflicted under torture then everyone who has pain has a choice about choosing to suffer with it or cope with it. But this again is getting way of topic of what the blog was trying to discuss which is in my opinion our species is becoming less tolerant to pain… not about specific cases or individuals!

              • Adam, I have no way of assessing the truth of your opinion that “our species is becoming less tolerant to pain.” However, could it be that physical therapists (together with physicians) are becoming increasingly frustrated by their inability to relieve the pain of their patients? This would induce them to take on board the argument that you have presented, thereby shifting the blame away from themselves.

                • That’s a good point I hadn’t considered… I will do now! However I don’t treat Pain, I treat people! And I’m my opinion many people are becoming less tolerant and suffer to easily! But I do accept I am also perhaps becoming less tolerant too! Thanks for making me think a little harder! I need to go and have a lie down now!

  9. Good post and ideas.
    The point is if natural history could heal the problem so what is our rule? And in some patients they have some rest before PHysio why nat history did not do anything for them?
    And the last point is when a patient could releive by a thing immediatelly why we do not apply that? Why tell him ” you will be good in 4 weeks “.
    We have to believe and accept that ” peoole needs quick probl3m solving approch now but we have to learn them it is not always true for all MSK problems

  10. Great article again! I had this experience just the other day, as a sports massage therapist who is training as a physio and has been lucky enough to train under some brilliant physios (and some less so) I really support the need to give patients the right information to help them live life with or maybe without pain and for them to understand that their pain isn’t necessarily an injury. Now in my line of work I see many people who as a physio student I believe need strength work and a small can of man up but unfortunately until I am qualified it’s the massage life for me and that’s what they’ve come to me for. I do however offer them information about the true nature of pain and the likelihood of their problem self resolving where appropriate but I am constantly shocked by how many people just don’t want to hear it and want to come back for another massage (even when I’m basically telling them not to… Bank account doesn’t look great as a result!) I sometimes wonder if people seek validation from a health care professional in that their pain is justified and that they need a plaster and a lollipop but they’ll soldier on and low an behold it’s all better in a months time. Sorry for the rant but my question is.. When you’ve given them all the tools and information that will help them, how do you get them to buy into that?! It’s the bit that involves them putting in some effort on their own but in the long run saves them money and keeps them living their life working to a pain reduced/painless life but it seems as if they think that is as likely as seeing a purple unicorn dancing dancing with a lepricorn! How do you get them in board?!

  11. Thanks for yet another great post!

    We work hard on exactly this problem with pain management at a specialized hospital for neck- and back-related pain and disability (both specific and non- specific), and we see a lot of people with non-specific pain, that cant handle their own situation. We try to use for example CFT in our work, but sadly the health care system makes it hard to get to the bottom with peoples problems, before they are sent back out of the hospital.

    People need to be teached in understanding pain and pain management, instead of just going to the doctor and get drugs an MRI/CT scans for no reason.

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