The hardest thing to do is... nothing!

An 8-minute read

The desire to help others is very strong in many physios; that's usually why they are physios. But sometimes this desire to help and do something may actually be to the detriment of those they are trying to help, and without realising it, therapists may be doing more harm than good for many of their patients.

If you have been watching the Olympics, then I'm sure you have seen a few of the athletes in the USA team appearing with neat circular bruises created by 'cupping' treatment that has generated a lot of discussion and debate on social media.

Michael Phelps 'wearing' cupping marks

This 'cupping' treatment dates back to the medieval ages and is believed to help reduce muscle soreness and aid recovery by lifting the skin under a suction effect beneath a cup, hence its name.

This suction is believed to increase blood flow and flush out waste products, toxins, etc., from muscles and tissues beneath.
 

It doesn't.

It simply creates nice, neat circular bruises from the pressure under the cu,p rupturing the small capillaries in the skin, and if I remember my basic physiology correctly, bruising the skin and creating rings of stagnated blood does NOT help your muscles or any other tissue recover or heal quicker.

If it did i'd be punching and kicking my patients until they were black and blue all over.

Personally, I think it's a daft treatment, and I can't see the point of using it in any situation.

But anyway its not cupping that we should be criticising per se, rather it's the ethos and mentality that many therapists have who feel the need to do something like cupping.

Why is doing nothing rarely an option for many therapists?

Is this simply their desire to help, or are other factors at play?

Regardless of therapist experience, training, or setting, be it in elite sport or your average NHS outpatient department, I see and hear many therapists doing some weird and whacky shit to their patients rather than doing nothing.

Be it cups, tapes, lotions, potions, machines that go buzz, needles, needles that go buzz, injections, and of course, manual therapy and manipulation. Many therapists just want to 'do' things in an effort to reduce pain and promote recovery that little bit more, that little bit quicker, that little bit extra.

These so-called 1% treatments have been the topic of discussion recently, with some defending their use in elite-level sport, and others have questioned their worth and the potential harm they can do.

Now I dont think cupping is that risky per se, some bruises and looking like a pepperoni pizza for a few days are usually the worst side effects. However, what are the benefits?

Well unfortunately there is no real evidence of any. Some say that's because it's hard to measure these small effects, others because the science hasn't caught up with the advanced nature of the treatments yet.

Usain Bolt getting his 1% treatment after his recent hamstring strain

However, there is another explanation that's far more plausible as to why we can't see these 1% effects, and that's they don't actually create any effect.

Now I don't want to get into the debate over the pro's and con's about using placebos, which has been done before many times. Instead lets look at the other side of these treatments, lets look at the potential negative or nocebic effects they could have.

The other side of 1%ers

The first thing to discuss is how big could the negative effects of these 1% treatments be?

Some assume that any potential negative effects of these treatment is proportional to any potential positive effects.

This is very dodgy reasoning, and if we were to apply this logic the other way around, then treatments that have very high positive effects should also have very high negative effects, but we often dont see this.

Simply put no one actually knows the size of the negative effects of these 1% treatments because no one can be bothered to look into it and do some research here.

However, there are some awkward and difficult questions that we should be asking about the potential harmful and negative consequences of these treatments, and our constant attempts as therapists to reduce, recede or remove pain in our patients or athletes.

And I'm not just talking about the physical risks but also the psychological risks, things such as...

• Are we reinforcing negative beliefs and fears for some that pain is wrong or harmful by always looking to reduce or remove it?
• Are we reducing the ability and resilience of some to tolerate future painful episodes by always looking to reduce or remove it?
• Are we creating a downward spiral of avoidance from perfectly normal activities that create some pain and discomfort?

This may seem counterintuitive to many, but we could be inadvertently making people LESS resilient and LESS robust to pain by constantly trying to reduce or remove it too soon, too quickly.

It may seem harsh and tough to say this, but whats wrong with experiencing some pain from time to time?

Ouch!!!

Pain is a normal and natural consequence of many things, such as after a tough session of exercise, or even face-planting into a diving board. However, pain usually tends to resolve with nothing more than time and little intervention.

Sometimes pain needs to be endured.

We know that by reducing your exposure to something, it can reduce your tolerance to it (think of alcohol as a good example here. Is it any different for pain?

Does constantly reducing your exposure to pain when you experience it lead to a reduction in your tolerance to it the next time you encounter it?

When a therapist attempts to reduce or remove pain does this mean it will now take less stimulus to trigger another experience of pain next time you train hard or have an injury? And then does it take more and more interventions to reduce or remove pain the next time around?

Double Ouch!!!

Does this constant reduction of pain after experiencing it lead to a lower tolerance to painful stimuli in the future (such as a kick in the nuts). But then, perversely, does this develop a higher tolerance to the methods aimed at reducing or removing pain?

Would we actually be better off simply saying to our patients that pain is normal, its nothing to be alarmed or worried about, and that it will pass?

Would we be better therapists by letting our patients experience some pain after activity and injury to allow them to develop exposure, resistance and resilience to it the next time it occurs?

Are we making people more fragile and less resilient by constantly trying to reduce their pain with manual therapy, tape, machines or cupping?

I ask myself these questions daily with all the patients I see.

I ask myself am I actually doing more FOR this person by doing less TO them?

My answer is often yes!

Now the other thing I want to stress here is that doing nothing isn't really doing nothing!

Doing nothing actually involves doing a lot.

And doing nothing doesn't mean you know nothing!

Explaining and reassuring a patient or athlete about all of the above and why they are ultimately better off NOT having all these treatments is A LOT of work, a lot of hard work. In fact doing whats best for your patient usually involves doing more work than doing what your patient thinks is best for them.
 

Don't believe me! Then try it!

Try NOT do the 37th session of spinal manipulation on the middle-aged sedentary patient with the lower back niggle that keeps coming back to see you on whenever they do a little activity.

Try NOT to put that Kinesiotape on the semi-regular runner for the 144th time who keeps getting knee twinges when they run more than 15k.

Try NOT to whack silly cupping thingys on Michael Phelps before he swims for his 287th gold medal in the Olympics.

Try and do any of these things and then tell me that's doing nothing!
 

The inconvenient truth is that it is far easier for us to appease our patients and athletes in pain or discomfort by offering and administering treatments like cupping or any of the 1% ers rather than taking the challenging, difficult, and seemingly harsh stance of 'doing nothing' and asking our patients to endure and continue on.

As always, thanks for reading...

Adam