Changes!

Is creating a quick change in our patients' pain and symptoms important? Well, there's no doubt that many patients come to us wanting and expecting a change in their pain, that's for sure. But how important is it for us to get these changes?

Do we have to change their pain a little or a lot? Do we have to change their pain immediately or over time? And how long a time is ok? And do changes in patients' symptoms help us choose better treatments or predict their prognosis better?

Well, many therapists do strongly advocate and promote the importance and need of achieving quick, significant within-session changes for patients.

We have the myofascial releasers, spinal manipulators, dry needlers, K-tapers, and electrotherapy machine users all telling us that quick changes in our patients' symptoms help them buy into our active treatments and improve our outcomes and success rates.

Then we have the Maitland and Mulligan advocates with their mobilisations, the McKenzie therapists and their directional repeated movements, and then the Jeremy Lewis fans with their shoulder symptom modification procedures.

They all claim that the key to successful treatment is in finding a quick and significant within-session change for our patients.

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 help them or to get successful outcomes.

Now, I didn't always think like this, especially as a keen, eager, naive, and annoying younger physio; I was taught and thought that if something was painful or restricted, I had to do 'something' to try and change it quickly.

This usually involved me pulling, poking, rubbing, or zapping the patient with something until they said it felt better. And when they did, it was an awesome feeling. The patient feels good, you feel good, the world feels good, and I was led 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 my job and work because the uncomfortable truth that no one ever talks about is that these significant immediate within-session changes don't always happen.

In fact, they dont happen more than they do.

I'd estimate that for every patient who got a successful within-session change when I did something, there were about 5 others who didn't.

No One Tells You This

This is what the tutors and gurus won't tell you.

They won't admit that most of their patients will say after some poking, prodding, rubbing, or manipulating... meh... nothing's changed... it feels kinda the same... or even sometimes they might say... WTF man, it now feels worse than before!

This doesn't feel good; this feels like shit. This feels like I'm a bad physio. This feels like I'm a failure!

So I went on more courses to learn more from the experts. I kept practising their techniques, trying to get better, trying to be more successful in creating these within-session changes.

But I didn't!

Many told me I was just not good at being a physio. And maybe they were right in some way. Maybe some people are just better at this hands-on symptom modification stuff than others.

But does this make me a bad physio? Does this mean I can't help my patients?

Abso-fucking-lutely NOT!!! 

Over the years, I came to realise that it didnt really matter if I got some patients feeling better immediately.

Because sometimes in those who I did get within-session changes with didn't always get better. And sometimes those who I didnt get any changes with, improved just fine later on.

Gradually, I began to realise that ALL these symptom modification techniques, be that Lewis's scapula or humeral head tests, Mulligan's MWMs, or Maitland's mobilisations, are unpredictable, unreliable and actually not necessary to help people get successful outcomes.

Now, of course, when they did work, they did help, but I also noticed that they all varied in how much and how long they worked for. 

Explain This Then

Now, some will say my lack of results are due to my lack of skills or experience. But how do they explain research that clearly shows results are not dependent on level of training or years of experience (ref).

Some will say it's becuase I didnt use the right techniques on the right patients. But how do they explain research that clearly shows randomly selected and applied treatments work just as well as those carefully selected by very experienced, highly skilled therapists (ref, ref). 

I have seen many times with my own eyes that I can use the same technique on the same person at two different times and get two completely different results. Conversely, I can use the same technique on two different people at two different times and get exactly the same result.

Now, the evidence about the need for us to create within-session changes to help guide treatments and predict successful outcomes is extremely limited despite all the strong claims out there.

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 strong or 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 within-session changes are widely spread, meaning we have little confidence in the strength of the association; it may just be that those that get within-session changes get better regardless of what we do.

And then there is the counter-evidence that within-session changes do not predict outcomes or help dictate treatment options (ref)

So although it can be nice to get quick significant within-session changes in pain 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 within-session changes with my patients, I began to realise that they were often a distraction from getting to the more important stuff, like discussing and exploring ways and means to create long-term changes in my patients' lifestyle and behaviours, and get them off the shitty quick-fix healthcare merry-go-round.

Lost Sight

In my opinion, many physios have lost sight of what good healthcare and treatment is. It's not just symptom modification, it's more so education, advice, reassurance, support, guidance, help and assistance for lifestyle and behaviour change.

Yes, ok, this is much more challenging and harder work than just doing symptom modification. But just because something is harder to do, this doesnt mean it's not worth doing. 

A lot of therapists in healthcare do only focus on the simple, easy, quick-fix approaches, and I can understand why, but for me, it's not the path of good, ethical, moral healthcare.

In my opinion, all of us who work in healthcare, be that physios, doctors, surgeons etc need to get better at assessing, educating, reassuring, and then supporting and guiding patients towards healthier, more active lifestyles rather than just giving out analgesics, massages, and manipulations.

Simply put, we all need to get better at educating most of the people we see that they don't need tablets, injections, massages, tapes or scapula assisted.

Yes, this takes longer to do. Yes, this is harder to do. Yes, this is a pain in the arse 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 fixes, and focus our efforts on the harder, more stable, more reliable, and more challenging long-term changes.

Summary

So, in summary, yes, we do need to create changes for our patients, but these don't have to be the immediate, instant changes that many advocate.

These days, I dont focus on trying to change a patient's pain immediately with the limited time I have with them. Instead, I focus on ensuring that their pain isn't serious or sinister, and that they understand what their pain is, how long it will last, and what they can and can't do to help it.

And finally, I focus on ensuring that they feel safe, reassured, confident, and in control of their own ability to get through this situation with my help and support if it's required.

As always, thanks for reading

Adam