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 slowly? And do changes in patients symptoms help us choose better treatments or predict their prognosis?
Well, there are many therapists who 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 in session changes for all our patients.

There are also the myofascial releasers, spinal manipulators, dry needlers, K-tapers, machiners that go buzz who also promote and bombard us with claims that getting quick and significant changes in our patients’ symptoms helps them buy into our active treatments and improves our outcomes and success rates.

I disagree

Despite these claims, I don’t think we need to change things that much or that quickly for many of our patients to have successful outcomes. Now 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 a 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 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 with this because the uncomfortable truth that no one ever talks about 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 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 didn’t always get better, and those who I didnt get any changes with did improve just fine.
I also began to realise that all the techniques are unpredictable and unreliable, and when they did work they all varied 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 (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, however, 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, and 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.
Of course, modern healthcare and medicine have 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, the shit that most physios see, it is healthcare’s meddling and interfering with this shit, trying to reduce, correct, and avoid it that has helped to screw 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 was 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