The paternalism problem in pain

The HIV/AIDS epidemic is a shining example of a successful response to a complex social problem. The creation of AIDS counsils by the members of gay, lesbian, sex worker and drug user communities who were hit hardest by the epidemic created a groundswell of community action, which gave impetus to governmental and non-governmental organisations to collaborate on sustainable solutions. The period is characterised by grassroots action, rather than a top-down approach, and a high degree of partnership between all level of stakeholders (Ref). This is a history you cannot say many other of our modern-day epidemics share.

The number of people currently living with HIV/AIDS is 37.9 million, which is dwarfed by the point prevalence of Low Back Pain (in 2015) of 540 million (Ref, Ref). Low back pain is a different and arguably much more complex problem, but it is helpful to draw parallels to successful solutions rather than proceeding blindly into the unknown. This blog will discuss the problems with the unwavering medical paternalism in managing this burden and explore the potential of a different approach.

Pain and suffering

Pain and suffering are two distinct, albeit highly related, identities. This is an accessible, very intuitive concept, even for the lay person; think of the young man who stubs a toe in comparison to the widow suffering through intractable heartbreak at the loss of her spouse – both are obviously in (different forms of) pain, but one is experiencing significantly more suffering, and it doesn’t take a rocket scientist to figure out who would benefit more from support. The ability to act in a ‘common sense’ fashion towards pain and suffering is a basic human function. It is something, however, that has wholly and solely become the role of the medical and healthcare system in recent centuries. The overt medicalisation of pain has been a fortuitous advancement in many ways, but many of these advancements have not lead to a reduction in suffering. In fact, we have had a steady increase in suffering and disability through this process; we have medicalised pain and watched by as mass suffering occurs (Ref). We have been able to produce more and more advanced ways of treating pain, but this has caused more disability, not less. Is this not evidence enough that our medical paternalism has ultimately failed the test of time in solving this massive burden of our time?

Pain happens within and amongst people; it has vital social aspects. Our medical and healthcare system tends to remove this vital human aspect of the phenomenon. What would you do to alleviate the suffering of the widow from the example above; you would talk and empathise with anyone suffering to this degree because it is a natural human response. In fact, you probably wouldn’t care to spend a fair length of time with this woman because you know, intrinsically, that the time you are giving her is valuable; it means something, it heals. We have a medical system that provides our health care providers a model that is all but void of this valuable resource. Time is in short supply; human interaction is lacking and our medical system ensures health care providers work to the rhythm of their diagnostic-curative drum. Musculoskeletal medicine has followed other disciplines down this winding biomedical road, much to the detriment of our patients. The model seems to have separated itself entirely from the most important element of pain and suffering; the social aspect. We have become very ‘sophisticated’ at treating pain, but we have failed to do anything meaningful about suffering. Our model has failed those it was designed to help.

Our model and systems are not only unfit-for-purpose, we also have a systemic under-appreciation of the social aspect of pain and suffering from translational research and policy. There is some data on what non-biomedical areas are most pressing to low back pain patients, of which specific social support is important (Ref). This is unfortunately rare and exploratory. There is a vast well of untapped potential amongst the community, who can not only shed a different perspective on the lived-experience of pain, but also be instrumental in co-designing a solution to mass suffering. We have forgotten the social aspect; the human aspect of the pain burden is an under researched, underappreciated and under-utilised component of musculoskeletal healthcare.

Ending paternalism

Paternalism is characterised by physicians making decisions for patients, in their best interest. It is characterised by doing things to patients rather than with patients. Surgery is an example of something done to patients and one that typifies ‘the end of the line’ for our biomedical model of healthcare. We have learnt that surgery for selected conditions in the areas of low back pain, knee pain and shoulder pain fails to make a meaningful impact in not only pain, but also disability and are also associated with significant risk to the patient (Ref, Ref, Ref, Ref). The evidence base investigating the true value of surgery seems mounting for selected conditions, but to be clear this is not a discussion on the merits or detractors of surgical interventions. This argument can’t be limited to surgical interventions only; although not associated with the same degree of (life-threatening) harm, other components of our modern-day healthcare system – of which conservative care is a part – is categorically poor at considering the patient perspective in any meaningful way (Ref, Ref). The approach of making decisions for the patient and removing their perspective from the process of care is what characterises paternalism and is what has characterised musculoskeletal care for centuries. Patient centred care may be a step in the right direction, but power imbalance is baked into our system of healthcare and to be clear patient centred care is still a product of this system. Is it time we take a leaf out of a successful approach to a problem – the HIV/AIDS story – and turn to our communities and our patients to determine the next best step? Instead of us determining what is best for those suffering from pain and continuing to search for a solution, should we instead ask them to become part of the solution?

While the medical system has not been doing a great job of managing this problem, what can’t be the solution is yet another false dichotomy where the medical system should absolve its responsibility to contribute positively to the pain burden. This should be a truly collaborative process, which is informed and influenced – at every level – by the patient. The patient is the consumer of healthcare but currently they largely struggle to have an informed, equitable say in the care they receive. We need a trusting and collaborative relationship to create care that is appropriate for all consumers, and this first begins with stepping down from a paternalistic position. There a few examples of consumer advisory groups bringing another perspective to care (Ref, Ref, Ref), but these are rare and don’t seem to percolate through the levels of power necessary to make a meaningful impact on policy and decision making. These groups don’t seem to have an equal stake in how care is offered, they lack a seat at the ‘C-suite’ table, maybe they are still outside in the waiting room. A medical solution to our pain burden should include these voices, not just at a tokenistic level, but to create a truly collaborative system from the bottom-up. A grass-roots solution and community voice is going to help us get to more sustainable and appropriate solutions to the pain burden; it’s not a dichotomy at all and it really can’t be moving forward.

Creating an informed consumer

An equitable and trusting collaborative approach to solving the problem is great in theory, but in practice it would be an incredibly naïve thing to rush at. Healthcare is an inherently disempowering experience and the route cause of this power (like many power imbalances) is information. To have a real conversation, we first need a system of information exchange that actually contributes to the end goal for each party. We first need a shared language and a dialogue that contributes to both parties being similarly equipped to discuss key issues. Health literacy is an important step, but like any language, just being literate may actually contribute little to the eventual success or failure of a conversation. In creating an information exchange so far, our approach to patient education has – in itself – been a rather paternalistic exercise. We have asked our patients what they need from treatment, but once again, this is predicated on a patient’s ability to adequately navigate what is a confusing and homogenous system. This is rarely the case, and what isn’t even clear is that if we have a health literate populace, will we see this transfer over in the ability to access, navigate and make sense of healthcare (Ref). A system of information exchange will need to rest on having some basic discussions about shared values and outcomes. Once again though, this probably isn’t the entire picture and we can logically assume that the entire picture wouldn’t be clear until we travel some ways down the road. It first starts with travelling down the road together, and asking some hard, but basic questions in the search of an informed consumer and an equitable partnership.

A conclusion

We may not appreciate how far we need to go to create an equitable and just consumer voice, and how deep the paternalism problem really extends in healthcare. There may be multiple layers, we need to unpack before we get to a point where we are ready to embark upon a journey together. Everyone would agree that the pain burden is unacceptable, but most of us continue to do what we’ve always done. We have a system that is categorically poor at inclusivity and acts in a top-down manner; this has not worked. The paternalism problem in pain is deeply engrained and although we may provide patient centred care, how equitable and sustainable are these episodes or solutions? It is time a real partnership is created and this begins with some hard conversations. An informed consumer is a long way off in the value-based healthcare discussion and we probably have a lot further to go than we would all care to admit.

 

 

ACL copers versus non copers; we need to do better.

Presenting the problem

Hopefully by now you know that reconstruction is not the only way to deal with ACL injuries. There is robust evidence to show that those who are conservatively treated are at no higher risk of OA and other sequelae (Ref, Ref). And hopefully, it is not news to you that you can even perform at the highest levels without having an ACL injury surgically managed (Ref, Ref). I’m not, however, here to argue the merits of conservative versus surgical management. Through this blog, I will contend that the most important first step is to improve the pathway immediately after an ACL injury. From there we can begin to understand when the surgical route needs to be undertaken (non-copers), or conversely in what population group surgery can be avoided (copers).

Houston.. we have a problem.

ACL injuries are responsible for a significant societal and economic burden and this might surprise you but reconstruction is shown to incur a cost savings (Ref), it is largely the recommended management after ACL injury. We are also, however, seeing revision reconstructions increasing at a rate of knots per year (Ref) and it seems if it were as simple as ‘reconstruction works’ then this probably wouldn’t be an observable trend. Us physios, unfortunately, continue to do a pretty poor job at ACL rehabilitation (Ref), but that can’t explain the explain the entire problem. Is the process of ACL injury actually missing an entire step? Possibly it should be ‘reconstruction works, in the right people, after the right pre-operative pathway’. In countries with national registries and nationally applied pathways following ACL injury, reconstruction rates are much lower; saving health dollars but also helping patients avoid unnecessary (traumatic) surgery (Ref). I’ve had 2 ACL reconstructions, so believe me, I know they can be traumatic.

In Australia in particular we have one of the highest rates of injury in the world, the highest reconstruction rates, a rapidly rising youth reconstruction rate (those under 14 years old) and no national registry – it is literally the Wild West of ACL injury (Ref, Ref). I’m worried about the future of our youth athletes and you should be too.

Like all things, there is no one size fits all and there is plenty of grey.

Copers and non-copers currently defined

It is worth stating, that currently, there is no known way to identify copers following an ACL injury (Ref). But for those with an ACL deficient knee, potential copers are characterized as having good knee stability and the ability to compensate well after injury, whereas noncopers have poor knee stability and less potential for compensation.

So what exactly makes up a coper?

A short synopsis of the (very low quality) research goes as follows:

  • In really simple tasks like walking, there is potentially increased hamstring activation in chronic (ACL injury >6 months ago) copers compared to non-copers (Ref). This might seem to make intuitive sense, in that there may be a ‘compensatory’ mechanism going on here.
  • There is some data that non-copers intuitively ‘protect’ the knee by reducing their extensor moment in gait (Ref).
  • Surprise, surprise quadriceps inhibition and loss of size was found as a common factor in all non-copers in some low quality studies (Ref, Ref).
  • Kinesiophobia levels would seem to be higher immediately after ACL injury in noncopers (Ref).

Caution! It would be wise to not make any conclusions about your patients based on the above data. In a multifactorial and complex condition like ACL injury there is little use in predicting the outcome from some simple initial data. A much better way forward is to ‘probe, sense, respond’ as you would with any other complex condition.

Current world best practice model which recommends an initial physical rehabilitation program for 3 months (called prehabilitation), it is only then that you can classify someone as a coper or a non-coper.

Currently, the best definition of a ‘coper’ is provided by the following criteria, proposed by Wendy Hurd and team in 2009 and since applied successfully by Wellsandt et al (2018) in a large cohort (n=105):

  • A timed hop score of ≥ 80% of the other side
  • A Knee Outcome Survey-Activity of Daily Living Scale (KOS-ADLS) score of ≥ 80%
  • A global rating score (GRS) of ≥ 60%
  • ≤ 1 giving way episodes (Ref, Ref)

This period of initial rehabilitation is then followed by a shared decision-making process to undertake a non-operative or operative management pathway. Considerations informing this decision are very individual including but not limited to, desired level of sporting participation, functional knee stability, occupational requirements, financial and time restraints and patient and practitioner knowledge and beliefs.

What does immediate ‘prehabilitation’ look like?

A really simple, clear 5-week pre-operative rehabilitation program initially proposed by Eitzen et al (2010) is called the Norwegian Research Centre for Active Rehabilitation (NAR) programme (it is freely available to view). In a prospective cohort study by Grindem et al (2015) (n=84), those that underwent this pre-operative rehabilitation fared better in all Knee Osteoarthritis Outcome Score (KOOS) subscales (Pain, ADLs, Sports and QoL) in comparison to a control cohort.

The rough outline to an immediate prehabilitation programme looks like so:Sample pre-operative program outline

Simple initial rehabilitation program ACL injury

The addition of perturbation training is recommended FROM DAY 1 in all ACL injured patients, so if you aren’t doing that it might be time to start (Ref, Ref). An example of perturbation program can be found here.

Putting it all together

So, if you aren’t going to ‘identify’ a coper early post-ACL reconstruction and world best-practice guidelines recommend for EVERYONE to undergo an initial evidence-based rehabilitation program, then I ask the Aussie physios reading; why aren’t we all doing this?

I’ve adapted this decision matrix from Hurd et al 2009:

Decision flowchart for acl injuriesDoes coping predict future success after ACL reconstruction?

 

There is now some evidence to show that improving the patient’s potential coping status improves post-operative outcomes (Ref). But what is more important, is that up to 2 years after ACL reconstruction, those treated with an extended period of pre-operative rehabilitation – the Delaware Oslo Cohort (n=150) – fared much better in IKDC, KOOS and had a significantly higher rate of return to sport than those who didn’t (Ref).

And it seems that once again, failure to regain adequate (>90%) quadriceps symmetry pre-operatively can have the potential to predict future RTS success (whether they will actually pass RTS criteria) (Ref). This makes intuitive sense, as it has been shown that you lose much quadriceps strength after ACLR anyway, so if starting from a lower base, you finish lower (Ref). Noncopers also seem to take longer to pass return to sport criteria following ACLR (Ref).

I think the salient point, however, becomes like anything we try to predict in the sporting or musculoskeletal realm; it’s bloody difficult. And the best chance we can do is adhere to certain stringent criteria along a structured pathway and attempt to reduce risk the entire way along this pathway. Once you have put your patient through a structured rehabilitation prior to any surgical decision, you will arrive at the important point; does this person actually require surgery or not?

A word on psychological ‘readiness’

The importance of psychological readiness to return to sport is becoming more apparent (Ref) and given that the studies involving a pre-operative rehabilitation program tend to demonstrate an improvement in subjective knee scores (KOOS, IKDC) then it could be entirely possible that this process is an important one for reducing fear levels and kinesiophobia AFTER reconstruction. There is no evidence available to back up this hypothesis, but I would think progressing through a rigorous, criteria-driven pre-operative rehabilitation program in which athletes are really tested and must meet high-level benchmarks would be providing the psychological ‘graded exposure’ that they may need in returning to sport – whether or not they receive a reconstruction is then simply ‘par for the course’.

We need to do better; a conclusion

I hope it is obvious we have a big problem on our hands. A problem for which the solution needs to be complex and involving multiple levels of clinicians, stakeholders and most importantly patients. There can’t be a one size fits all solution and just reconstructing everyone’s ACL doesn’t seem to be working now does it? It certainly hasn’t helped the patients, it hasn’t helped our health system dollars and it’s made us physios look kind of bad (depending on your perspective, this might be a good thing..?). Into the future, this problem will be hitting our youth athletes hardest and causing a significant burden if something doesn’t change. In order to effect change, I will leave you with a few key takeaways on what we need:

  • A concerted effort for everyone to become more aware of current evidence regarding the nuances of ACL injury and rehabilitation.
  • Clearer national level guidelines and pathways for practitioners in the immediate post injury stages to guide decision making.
  • Shared decision making instead of unilateral decisions based on General Practitioner referrals.
  • More structured rehab approach both pre-operatively and post-operatively.
  • Criteria driven rehabilitation and prehabilitation post injury.
  • Less fear amongst physiotherapists and more willingness to push patients to achieve excellent outcomes.
  • As always, more research into the above areas to define the problem and to provide information – based on clinical input – on what works and importantly what doesn’t.

Once again, thanks for reading.

Spectrums; a sociopolitical perspective on pain

When some of you hear this blog title, you may cringe, or turn off in angst. What kind of dickhead blogs about politics and pain!? Well, I do – I blog about politics and pain because I think they have a lot to do with each other. Let me explain.

Spectrums are everywhere we look. And the zeitgeist of the time pushes the ‘popular opinion’ pendulum between each ends in none moreso than allied health practice and musculoskeletal pain treatment. Here are just some of the spectrums you might recognise.

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Now a few points:

  • The arrow is a pendulum, NOT MY PENDULUM. Because, before you ask, I would consider myself a radical centrist in most of these spectrums (just like my political bias itself..).
  • The pendulum will always swing to and from one end of the spectrum, and I’ve placed it fairly arbitrarily to an end that captures what I believe the current Zeitgeist translates to.
  • No, I’m not saying these things are a spectrum at all. In fact I think these things people should be able to hold multiple conflicting ideas and ideologies in their head at once, making these spectrums redundant – more like a circle – and in fact, some people obviously can. So if you are one of these people, stand up loud and proud and I mean no offense.  

In the political realm, the left-right spectrum is relatively new – French Revolution of 17th century is where the ‘wings’ were originally coined. And just like in my imaginary spectrums above, it is very arbitrary – because multiple issues will be taken in an individual context and it’s obviously very common for someone to take a ‘left’ stance on one issue and a ‘right’ stance on another. It’s really imperfect, but it is what we’ve got currently.

What happens to Pendulums?

They stop swinging and generally settle somewhere in the middle. So I think the salient questions are is this a good thing for treating people in pain? My opinion is that in some instances it is not. And secondly, is this actually going to happen in our realm? Will we have a settling effect? My initial thoughts are that the evolution of clinical practice has been drastically sped up by the uptake of evidence based practice and my spectrums above don’t really do this fact justice, so maybe we will have a constant march towards improvement. Then again, some say this is the case in the political sphere as well.

A sociopolitical spectrum of pain?

Now, try to get rid of any of your political bias for a second and tell me where you lie on this spectrum?

sociopolitical perspective on pain

Once again, put aside your political bias and hazard a guess at which one is better for the society.

I’m not calling you a socialist, but are we all ‘pain’ socialists?

We all got into this game to treat pain. And it is fairly clear, that presently, what has been happening for the past 40 years has not actually been treating pain. There is some evidence to show it is actually increased by our presence (Ref, Ref, Ref). Now, I think we need more evidence before we go bandying around the notion that we – as health professionals – may have actually been contributing to a global burden, rather than helping it, for the past 30 – 40 years, but I have blogged about this before and I do think we have a lot to answer for.  Our system for managing this global burden has not been working, we have not been solving a problem, we have – if anything – been simply ‘farting in the wind’ as the structures around us ramp up a pain epidemic around us. Asleep at the wheel.

Things are different now, though. At least from where I stand. People are waking up to the power of their words, the power of the way they manage people who have high likelihood of becoming a chronic pain patient. There are a lot of good people out there who are now trying to turn the tide and get the message out. That we need to do better, that we need to change the way we are doing things to ensure we no longer sit idly by and watch the steamroller of persistent pain envelope our society. If you are reading this, then you already know who these people are – people like @thesportsphysio, @drjaraodhallpt, @bencormack, @thephysionetwork, @thefreshmanphysio, @hannahmoves, @thekettlebellphysio – I could go on and on! These people are working hard to promote better clinical practice, higher value care and to change the way we use lower value interventions that create dependence and disability.

Whether you like the term socialist or not, you are probably reading this because you think we can do a lot better – individually and collectively – to help the collective (no, I won’t call them the proletariat ! ) in pain. And what I mean here is that, you are part of a community that is bandying together to change minds, change practice and alter the course of the ‘old way’. Maybe we should call ourselves radicals, not socialists. But we are definitely doing it for the good of the whole of society, so give yourself a big pat on the back.

So what camp do you belong to? Can you get other people into our camp? This is, unfortunately, going to sound very Marxist, but here goes.. Viva la Revolucion! We need a new world order, and are you going to stand around on the right or are you going to fight with us on the left to change the pain burden experienced by society?

 

Quantum blog #3: Reality really is relative

Welcome to the last instalment of this series on Quantum Mechanics, focused on our perception – and therefore our patient’s perception – of reality. This topic is so relevant for any clinician and you may be thinking that, ‘this is A, B, C stuff, so why the hell would I waste 5-10 minutes of my day listening to you ramble about it?’ Well, it’s a good question and hopefully I can answer this in one blunt statement, ‘is it really that simple?’

Do we know all that we need to know to make firm conclusions about this topic? If you have been following the last couple of blogs on Quatum Mechanics, or are scientific in any manner, then the answer should be pretty evident – absolutely not.

But, to be honest, I start from the same biased position as many of you might when entering this topic – it should be very simple, to understand our patient’s perspective. In fact, going further, one might think (and I tend to agree) that we get told this is a core skill as a health professional. After all, allied health professionals are meant to be the experts in empathy right? Seriously, there is data here – we’re supposedly better than doctors AND EVEN TRADITIONAL CHINESE DOCTORS (Ref). So, in my mind, the ability to appreciate and understand your patient’s version of reality should be simple, it should be the mark that separates the good clinicians from the great clinicians. At least, this is what I’ve told myself for the past 10 years (yes I told myself this at university… OK!?).

Once again, though, if we understand anything about the natural world and the make-up of the universe, is that it may not be that simple. And maybe what we do, when we apply our expert analysis of the perception, drivers, intent and behaviours of our patients, isn’t what we really think we are doing… Let me explain.

550px-Neural_Correlates_Of_Consciousness
Consciousness; is it actually this simple?

Theory of Mind

Theory of Mind is the ability to recognise and attribute mental states – thoughts, perceptions, desires, intentions and feelings – to oneself and others and to understand how these mental states might impact behaviour. (Ref)

We’ve all got it, apparently. Like an X chromosome, it’s an innate trait that we are born with. It develops as we age and interact with other humans – sometimes it can go astray in conditions like autism. It explains why you can delve into your ‘heuristic’ system of thinking – System One thinking – and pretty quickly come up with a map of why your patients may have come into your cubicle or clinic. You attribute intents and desires behind their actions and behaviours, and there you have it, you start with your first question,

“Tell me your story”

I’m not saying that your practice of attributing meanings is wrong, mind you, just that it is not quite as right as you might think. And don’t worry – I still think starting with the above question is absolutely the best way to go in the clinical scenario, because what else do we have if not the patient’s story – a bunch of meaningless tests, amongst meaningless data, which doesn’t correspond to the patient’s phenomonen of pain – useless as tits on a bull. For reals.

To my point; the theory of mind, our practice of this in clinical situations and in general daily life is simply the process of human’s telling stories to themselves. And you can weave a story any way you like, it doesn’t make it real. The theory of mind, believe it or not, is still just a theory; there is not and never will be, any discernible evidence for thoughts or feelings attributed to actions – these are stories we use to understand how other people behave. The issue with people, is that they are unpredictable and their story might not match yours – because after all, you got into this game because you are a rational, reasonable and thoughtful individual – so unlike your patients right!!? So maybe the mountains of data that you diligently get from your patients isn’t the only thing you collect, that is useless..

Let’s get this out of the psychological realm – because I am woefully out of my depth – and bring this into the quantum realm – where.. I am even more woefully out of my depth.

46A93C7200000578-0-image-a-38_1511535374638

Perception is reality

You’ve heard of Schrodinger’s Cat. Great little thought experiment – there’s more wacky people doing these – from none other than Edward Schrodinger (get right out of town!), which elegently poses the problem with interpretation of quantum mechanics. That is, that any quantum phenomenon (like atoms, which we are all made up of), can exist in multiple states at once, until observed – or interacted with – by an external system. It is the process of observation that makes the world so, in short the world actually is really what we make of it.

Observation causes the wave function collapses into one definitive state – reality. But it is slightly more complicated – observer and object are then instrinsically linked and coupled – to form our reality. One cannot exist without the other.

It doesn’t take Einstein – or Schrodinger – to figure out where this is going. It is a fundamental fact of the natural world that your patient’s reality is theirs, and only theirs. We know that the pain phenomenon is a subjective experience, but now you can back that up with quantum data! It might only really transmit if your patient is a physicist though.. so probably don’t mention that.

So what?

Ok, so I have rambled for long enough and present my two presuppositions. The theory of mind is just stories we tell ourselves, no more real than any fairy tale you listen to as a child. And the nature of reality is such that it is truly a relative experience that can’t actually be shared by another conscious being. But what’s the takeaway you ask?

If you understand that your patient’s stories may not mean as much as you think they do, then this can be a liberating experience. Once you understand that some stories exist, in our patients minds, not actually in reality, simply to exist and not to impart meaning onto actions – because we may actually simply create that meaning in the first place – you may be left with a sipmle decision. Where do you want their story to go? Who cares where it has been – it doesn’t mean much anyway!

This is another way of saying something I have been saying for years, and maybe what has lead me to progress into the roles I am now in. If we get caught up in being reactive, and ascribing meaning to where there may be none – in a patient’s pain presentation – then there is limited room to change the future path for them. Do we want to manage someone and create no change, or do we want to look to the future for them and help them create that change? Rhetorical question- I think you know my bias there.

So if reality is relative, how to we get their ‘story’ headed in the right direction? Again, a fundamental theory of how the universe works, tells us that we live in an uncertain world that is only made concrete by our conscious perception. But extrapolating this is when things become very interesting; an uncertain universe means that the future is far from certain. Their reality is of their making, and maybe just maybe, they can understand that it can be different if we get this concept across.

Our job is to be teachers and open up more possibilities. Everybody – I mean absolutely everybody – is ultimately limited in their perception of reality, but people who come to us for help are much more limited. Our job is to open the door to other realities.

Teach an understanding of avoiding absolutes and understanding that pain, injury, difficulties are all going to happen – they are a natural part of our existence, in an uncertain, unpredictable universe. There are some simple things to practice to increase your adaptability to this uncertainty, namely being durable, potentially even anti-fragile. But nothing is unavoidable because of our uncertain universe. The beauty of our uncertain universe, however, is that we can choose any path to the future, there is always room for change and nothing is set in stone; it is up to us to demonstrate this possibility to the patient.

Once again, thanks for reading.

A heartfelt apology to my patient

I am writing this to say sorry to you. I’m sorry for a lot of things and through this I hope you understand more about what you need to be expecting from your health professionals and your health system. I am sorry for all of the bad experiences you have had. I’m sorry for all of the people like me that haven’t done the absolute best they could to help you. I want to apologise for them, because if I don’t you’re going to continue to think a certain way about us. When you come to us, you expect a certain level of service, and over time this level of service has probably not met your expectation – or if it has, you may be unaware of some things that could be better, things could be different for you. I promise that some of us are different, some of us think differently, we act differently and the health professionals like me want what is best for you and will do everything we can do to truly help you. I promise that you should be expecting more, you shouldn’t be settling for what you have had in the past.

Before I do that, I want to explain to you why it is difficult for health professionals to give you the experience you deserve. I want to explain why it is hard to manage people in pain and why it is hard to ensure you have a lasting resolution of your pain. You see, when you come to us in pain, you may also be troubled by other things. It isn’t obvious to you, but it is something we know also contributes to your pain and sometimes can be one of the main drivers for it. These other things make treating you more complex, and unfortunately we can alert you to these other things, but we can’t actually do very much about these things. These are things like if you’re having a stressful time at work or you may have had family issues for a while. We can’t change your boss, your colleagues or your family; we know they impact on your pain but we can’t change them. We can, however, let you know about the impact this has. In fact, there is a lot we can teach you and that is where I will, once again, apologise for those who haven’t taught you more. Because although there are some things that make your pain worse, which we can’t change, there are so many more things that we can change. This starts by simply telling you about these things, and I’m sorry for all of those health professionals that haven’t done this. When you come to us in pain, we know the best things you can do is not be afraid of that pain and to understand that you are not fragile or broken. I am so sorry for those people who made you think you were. If you knew more about how wonderfully fascinating your body and brain are, when they work together to form the feelings you associate with your pain, you would be as interested in it as we are! You wouldn’t be afraid of it, you would marvel at the amazing complexity, but awesome simplicity with which you are able to protect yourself. If only you knew more about the things that make your body and brain become overly protective and the things that make you think you are capable of less than you actually are. If only you were taught about these things by all those previous health professionals, instead of those people letting you continue to believe that you are less than what you actually are. I am sorry that you were lead to believe that you are less than capable, I am sorry that you think you are fragile, I am sorry that you have had to deal with health professionals that have never told you otherwise. Because the truth is, you are more durable than you know and capable of so much more than you think.

So it might be difficult to treat you when you come to us in pain, but it isn’t difficult to teach you some simple things that will always help. It is easy to tell you to stay positive about the outcome of your pain, because most things – and I mean most things – do get better whether you come to see us or not. It is easy to tell you to keep moving and to not be afraid of causing more damage, because these things help the most. These things are easy and I’m sorry for those people who don’t make you remember these things above anything else. I’m sorry that you end up confused and think your problem is more complicated than it needs to be. It really can be different, and we are working on it; but we need to be better for you and make you believe in yourself, your health and a better future.

For all of the thoughts, feelings, stories and yarns that you feel and have told yourself about fear and fragility; I’m sorry. Because I know that people like me probably caused a lot of that, and you trusted us to make you better, not worse. I am sorry that we are failing you when your only expectation of us is to help you. We are doing our best to change things, but it is still not enough; we need to be better for you and give you the experience you deserve, not a dim version of the one you’ve come to expect.

I will say, though, when you come to us in pain, sometimes you want to get better so much that you place all of your hard work on our shoulders. I’m sorry about this, because sometimes we are not brave enough to admit how little input we actually had into making your pain better. We largely do very little, and that’s the truth. I’m sorry as well, for all of those practitioners, who let you think it was only them that made your pain better. I’m extra sorry for those practitioners who preyed on you and ensured you returned to them week after week, year after year, whilst never actually giving you any way of helping yourself. I’m sorry that you’ve never been given the skills to help yourself and manage your pain like any other normal thing you have in your life – like getting old or changing jobs. You’re probably pretty well equipped to deal with these things, but somehow you’ve never been shown how to deal with pain in your life – well it’s pretty normal too and I’m sorry that you think we have all the answers. We need to do better, and believe me we are trying, to ensure you know the answers just as well as we do.

Most of us are trying harder than ever to find the answers and tell you, but some of us aren’t. For those professionals that you have seen that don’t pay attention to the up to date information, I am not only sorry, I am angry. And you should be too. We live in a more connected world than ever, with more information available at our fingertips than the entire history of humankind. For those people that don’t pay attention to this information in order to give it to you, there is no excuse for this. If you have come across professionals who do have their head in the sand; they were lazy and it hurt you in the process. You should expect better from us and don’t settle until you find it.

I’m sorry for all of those practitioners who made you think they had the answer, or a quick fix to your pain. I’m sorry for all of those practitioners who told you, ‘I definitely know what’s wrong with you.’ It hasn’t helped you and it’s just made you lose confidence and trust in us. The truth is, there is no miracle cure and sometimes we have to accept that we don’t know the exact cause of your pain. I’m sorry if you still believe there is a quick fix and that you just still haven’t found that one person that can find out the one thing that is wrong. It is understandable that you think that when you come to people like me, because you see it everywhere you go. I will say, it is difficult to do our best in a health system like this, where you see promotions for ‘pills’, ‘fads’ or ‘the latest gadget’ on everything from the TV, internet and social media. You’d be forgiven for thinking that this is, in fact, the best way to go – a nice quick, simple fix. But once again I need to apologise for those people, those companies and those platforms that make you believe this. It isn’t easy to get to a good place with pain, it takes a lot of hard work and time, but because of all of those things this is time you don’t want to spend. It’s not your fault, it’s ours; we need to do better for you. We need to tell you the truth about your pain and what you need to do to improve, for that I am sorry. For you to trust us again, you need honest health professionals and an honest health system, so let me start that off by apologising to you.

Take this as a heartfelt apology about not doing the best we can for you. We will encourage those that aren’t trying to be better for you, we will continue to search for the answers and be honest with you when we don’t know them. Please understand that we are trying and if you have been treated by someone who isn’t trying, then uknow that we’re not all like that – in fact most of us aren’t like that. If you are still being treated by someone who isn’t trying, then go find someone who is; you’ll be better for it and you can thank me later.

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Quantum blog #2: Durability, anti-fragility and … Quantum Mechanics

If you stuck around from the last blog, the first blog in this series related to Quantum Mechanics, then congratulations.. You made it through one of the least topically relevant pieces of absurdity that quite possibly exists in the health blogging atmosphere. If you’re just tuning in, and want to make your eyes bleed, then take a look at the first instalment in this series of blogs linking Quantum Mechanics and health issues here – seriously, it might make more sense to start at the beginning.

Or it might not, because if you learnt anything from a brief introduction to Quantum theory, it’s that not much makes sense. The world is, for all intents and purposes, a non-sensical place.

It is a place where, whether you want to believe this or not, randomness and chaos are the major players in daily happenings. Your daily schedule, which may be planned out to the micro-second (or not, if you know what’s good for you), is a futile attempt to create order in a disorderly universe.

You’ve heard of the Butterfly Effect? Yes, that movie with a verile Ashton Kutcher, which came out wedged around the time he was trying to air the stench of ‘Punk’d’ from his life and just before he got some baby-mama drama with Demi Moore. Well, it’s kind of related – it does a pretty good job! If you’ve seen it, you get the premise; a small change in a system can have drastic (larger and non-linear) effects at some other point in the system. It’s actually best explained with the title of the original article written by Edward Lorenz who presented the theory, ‘Predictability: Does the Flap of a Butterfly’s Wings in Brazil set off a Tornado in Texas?’. To trace this back a step, you may want to understand a little bit about Chaos Theory. Of which, the Butterfly Effect explains one aspect; the sensitivity to initial conditions is just a nice way of saying that when you have a small change somewhere, the divergence and chaos in the natural world ensure that you get a much larger change and effect further down the line. Chaos Theory also states that as you increase the time gap in your predictions, you increase the level of uncertainty about that prediction. But, of most importance, chaotic systems should actually be predictable if you know enough about the initial conditions and variables that impact the system. The problem generally is that, in order to get a full understanding of variables and initial conditions, you need to spend a long time gathering information. There are biological applications to Chaos Theory, but in my opinion, not nearly enough about one of the most important aspects to daily human life – movement.

In order to get more immersed in the field of randomness, then you must also understand a little bit (because that’s as much as I know) about complexity. Watch this quick video explaining the Cynefin framework of determining the best course of action when you are presented with various types of problems. When dealing with a lot of natural phenomenon, we are actually dealing with complex, random systems. So the following discussion is based on two presuppositions:

  1. Human movement is chaotic

  2. Human behaviour is complex

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Now to the juicy part and I want you to tell me; when you are dealing with patients, are you dealing with either of these problems in isolation? Probably not right.. So we need to understand the kinds of problems we are dealing with, and have an appreciation for when dealing with either, there may be different strategies to use. Lastly, what I want to get across, is that, it is our job to instil these kinds of strategies in our patients, and most importantly, we also need to help them understand these strategies for an empowered and functioning existence into the future.

Movement is unpredictable

Some background for you here, there is work into motor control and chaos theory. Mathmatical modelling in human movement is obviously not new, there are many a degree to undertake if you want to understand kinematics better. A read of Glazier & Davids (2009) review on current understanding of ‘self-organizing optimality’ may help you better understand where I’m coming from. The human movement system and performance optimisation may be best understood as a dynamic interplay between external factors impinging upon an individual. This co-ordination is self-organising, always individual, adaptive to all factors and dependent upon conscious and sub-conscious intepretation of all factors.

To put this simply, movement is an output of a chaotic, self-organising system. If you are stuck in the stone age of the ‘top-down’ motor control model, this may be a shock, but that’s a pretty simple take on a really bloody complex problem – movement – and you didn’t think it really was that simple did you!?

Some people may have read Frans Bosch and can resonate well with the idea of a self-organising system. But, he’s actually not just ‘crazy Dutch-man’ making this shit up whilst he smokes a bong and eats a pancake..

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He’s actually basing a lot of his work off some hard science into investigating motor control developement by Newell and colleagues and Kelso and colleagues. Movement – and the enhancement of this movement – should be seen as non-linear, chaotic and another biological system. Not the way it is currently viewed, as linear and mechanical.

Movement and performance is chaotic; it is non-linear, it has the capacity to be modelled, but is ultimately unpredictable.

So what are we doing when we rehabilitate or train?

Why do we squat? Why do we lunge? There is no doubt that there are some common movement patterns that are commonly performed by everyone – whether athlete or not. If you read Frans Bosch, you may think of training these movements as ‘deepening the troughs’ of ‘Attractors’. In other words, making a primary movement pattern easier and more co-ordinated. This sounds pretty neurological right? Well for the most part it is, but we are doing so many other things as well, however, and if aiming for muscular hypertrophy – which in itself is an incredibly vague term – you are creating a physiological response from muscle cells to create more ‘substance’ from which to create force. I think you can tell that this topic, in particular, could go on for a very long time.. Ain’t nobody got time for that and you probably want me to get to the point.. When we train – or rehabilitate – in the typical, common fashion, are we actually achieving much when it comes to the complexities of movement and performance? With a basic understanding of ‘dynamic systems’, heck even quantum theory, do these very predictable and orderly movements actually relate to movement in real-life??

Here’s what I think; I think there are some movements you need to perform well. These are our ‘attractors’; a non-exhaustative list is:

  • A squat pattern
  • A hinge pattern
  • A single leg squat pattern
  • A single leg hinge pattern
  • A horizontal push pattern
  • A horizontal pull pattern
  • A vertical push pattern
  • A vertical pull pattern

These are well established as primary movement patterns and comprise the basics of any comprehensive program. These movements basically just help you load someone up in a movement that someone else has designed an exercise around. It’s easy because unless you wanted to spend hours and hours trying to account for all variables in a skill and create each exercise based on that, these put simply just save time. Allow some physiological adaptation, but aside from that, I think they’re pretty useless. Most of our job needs to be to consider elements of unpredictability as these elements of ‘challenge’ mimic the real world and allows the system to self-organise. I think we need to be more aggresive and early with our ‘real-world’ challenges. It’s a lot to hold in your head, as you do need to understand tissue healing, strength training principles and periodisation but once these basics are fulfilled, there needs to be a real focus on increasing challenge on the system to create a more efficient self-organisation. I don’t think this challenge always has to be load either, I think we need to get creative with exactly how we are adding complexity and randomness to things.

So, do we achieve normal?

What is normal? You can prepare the body into any ‘perfect form’ that you wish, but ultimately what are you ahieving? The perfect biomechanical picture in many cases is not actually predictive of anything much except an projected idea of ‘normal factors’ gained from a ludicrous cherry picking of various aspects of movement that we know about, which have been arbitrarily linked – at best a retrospective causative analysis – in a controlled fashion. The obvious problem here is that retrospective causation does not prove prospective risk, because the future is ultimately undeterminable. This is especially true with something as complex as movement. There are countless example of ‘abnormal’ biomechanics being not only useful, but the most efficient:

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I know what you’re going to say here, ‘but Connor, you’ve railed against that logical fallacy in the past – the absence of evidence is not the evidence of absence- yadda yadda..’ And I would say ahaha! Right you are sir, but I’m not saying that we should all start to teach over-pronation and valgus in our squats, I’m saying that our practice of always avoiding things that we determine as ‘biomechanically incorrect’ is probably really flawed. We use these ‘biomechanical’ markers on a massive scale, with religious vigour, when it should only ever be another element to consider. If someone’s self-organising system has determined the best way for them to perform the action, is achieving ‘normal’ something that we need to spend much time on? Maybe we just need to have the basic pattern there and then start challenging the system (with load for example). In short, are we actually preventing anything if we get someone to do the perfect squat 100 times over? I want to add to this, that I really don’t know here, and think that the answer lies somewhere in the middle of ‘perfect form vs natural form’, but I also think we are a long way from the answer at the moment with our current practices. If we follow the Cynefin framework, we are trying to achieve stability in our interventions in a chaotic problem like movement. We want to force the system to create stability in different ways to avoid large ‘butterfly effects’.

So, do we prevent injuries?

If a system is truly chaotic, there is a limited chance of predictability, and therefore prevention of events. That doesn’t mean there are things we can do to protect ourselves against randomness. Understanding that most stable systems have very nuanced, multi-layered adaptations that have evolved to reduce disorder and create stability is a start. To reduce disorder is what we need to do and implementing things that do this is important like, reducing spikes in load – after all that is a disordered challenge on a stable system. I am particularly interested in taking the ‘prevention’ and reduction of disorder one step further. This is where we bring in the concepts of anti-fragility and durability.

Anti-fragility and durability

If a system is designed with minimal variables, then any change in one will have a catastrophic effect to the output. Movement is no exception, if we keep movement simple, then any change is inherently going to destroy the output that we want. For example if you only ever practice a squat with a box, and are then asked to perform this same movement free-standing with a bar across your back, you will have buckley’s chance of doing it right. This is a simple example, but if you extrapolate this to running and cutting like in a game of football, then you can see the issue. If you always practice with no challenge, then you sure aren’t durable.

So exposing the body – and motor output – to challenge is key to ensure more variables are incorporated to force stability. Once again, I think we need to be more genuine and thoughtful in our approach here. Enough challenge to force stability over time rather then to over-challenge is key. Because we will never approach any kind of worthwhile prediction in a chaotic system, interventions that challenge the system enough to stabilise and reduce the effects of further randomness are king.

In applying this to every day athletes or patients, it probably doesn’t matter how much they can bench press or deadlift after a certain point, what is key to being a more durable person is exposing yourself to a multitude of different movements, forces and situations.

Anti-fragility

Taking durability a bit further is then speaking about being ‘anti-fragile’. The concept comes from some of Ido Portal’s work and Nassim Taleb’s book of the same title. Essentially, in some systems, those that improve with disorder are then more ‘anti-fragile’ and resistant to failure. Common training programs do pretty much the opposite of improving your capacity to deal with disorder – they train you in repeating the same simple movement task over and over.

We need to start to think this way in performance optimisation and rehabilitation. And once again, we want to start thinking this way earlier in the piece to improve our outcomes. Exposing yourself to random movement is a good way to, at least, be prepared for the unexpected future. It is the opposite of ‘chasing normal’ and needs to be practised. But, I do think that once again, the answer lies somewhere in the middle; always practising random movements leaves no room to get genuine physiological adaptations for other key movements. These are our key exercises that we can use to apply basic strength trianing and overload principles. Once we have the basics covered, we need to force stability in other areas.

I do have some bias here, and you can probably tell. But I don’t think it is a bias that prevents the discussion about the reality of human movement and the natural world. We live in an unpredictable, random world and human movement is one chaotic system designed to reduce disorder and create some kind of output. If put in terms like this, I think the only way to produce a better output is to create a more stable system, and being logical the only way to create a more stable system is to force it to reduce disorder, force adaptation and expose it to more randomness. Not less. Our job should be to improve the capacity of individuals to appreciate this and learn to expose themselves to different movement, varied movement and continue a practice of anti-fragility.

Thanks for reading, and you wouldn’t believe it, but there’s more where this came from in the next instalment about quantum mechanics and the complex problem of patient behaviour. The underpinnings of perception – reality or just their reality?

The problem with the ‘Quick Fix’ explained with Quantum Mechanics

You may be thinking, what the hell does Quantum Mechanics have to do with a health blog? Well, I’ll tell you! And if you stick with me, there is some gold at the end of the rainbow. We can actually learn a lot from understanding the make-up of our universe and it can apply to some key principles in clinical practice. I’m going to do a series on Quantum Mechanics, so there’s plenty more where this comes from, and essentially if you don’t like thinking about physics, then you best tune out for a few weeks.. Please don’t.. I’m also most likely going to butcher the science here, so for any quantum physicists reading…..tumbleweed….cough.. OK, so for any of you who know a little bit about this, hopefully this doesn’t hurt the progression of the field too much.

When you think about it and apply some basic principles, the natural world becomes a fascinating, terrifying place of uncertainty and our living experience is a very limited and restrictive phenomenon.

–        The world is complex

–        The world is unpredictable

–        Quantum mechanics means events are fundamentally immeasurable.

–        Quantum mechanics means that when two systems interact, observation is only relative to the person observing it. So reality is, truly, relative.

The uncertainty principle and complexity

If you didn’t already know, pain is one of the most pressing global burdens; come on guys I write this in pretty much every blog post.. Keep up. One of things we see in clinical practice, that in my opinion is a major factor in propagating the trends we see in this global pain burden, is the creation of a dependent patient and financialising of those that suffer from very thing we want to treat, cure and manage. Once natural history, treatment seeking, placebo and other contextual nonspecific effects take hold of any clinical interaction, what is fairly clear is that the actual treatment effect may remain fairly small. Clinicians who are not able (or sometimes – worse still – not willing) to (either cognitively – or again – in conversation with the patient) separate themselves from this myriad of effects are piggy-backing their apparent ‘intervention’ onto these factors, essentially rendering all responsibility of the patient in all of this null and void. But I am aware it is called business, and repeat business is good in allied health clinical practice. Business is booming.. Which can be a good thing, but also leads to some more ‘unsavoury’ elements of competitive practices. One of which is promising a ‘quick fix’ to pain – whether this is manual therapy, exercise therapy, or any other therapy you can think of. The quick fix externalises any form of personal accomplishment from the scenario and places it squarely on the clinician’s shoulders. and I want to argue that from a theoretical standpoint, the very structure of our natural world is at odds with these kinds of claims. The very fabric of our reality does not support the ‘quick fix’ claims.

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The principle that is at the core of Quantum Mechanics states that we can generally only give approximates about the probabilities of ‘reality’. Watch this video and then report back.. Right, what have you learnt? If you are like me, then about 2m30s in you went cross-eyed and are fully able to appreciate my point underlying this. The human brain is inherently very poor at working in the space of uncertainty and really, really bad at understanding probabilities. From probably the number one book I can recommend, Thinking Fast and Slow by Daniel Kahneman, it is pretty clear we are hard wired to actually ignore probabilities and uncertainty. We have very well established – but very efficient – thinking apparatus, which comes to generally pretty accurate intuitive conclusions, but these conclusions completely miss the nuances and complexities of the natural world and one of these is definitely how uncertain everything actually is.

Human beings want absolutes, we want certainty and control, because it is far more palatable than the alternative. We are horribly ill-equipped to deal with all of the uncertainty, and this is especially true about our physical health. There is nothing more absolute than promising to ‘fix’ a complex problem like pain. And so patients are no different, they absolutely eat that s&*! up! Who doesn’t want a good quick fix! Aside from the obvious fact that it is easier than a ‘long, significantly more effortful fix’, it is concrete and is absolute. It has been shown that, in patients with low back pain, they really do have some concrete expectations on a few matters (Ref):

  • Diagnosis
  • Clear instructions on what to do next
  • What the next steps are in the diagnostic process (for example imaging)

It is obviously important that we give consideration to providing these absolutes when warranted by an individual and as health professionals, we do have license to provide these absolutes. But we really don’t have the license to provide anything much more than this.

As health professionals, we are also taught critical thinking and the scientific method. We really don’t know anything is 100% true, even things that have been proven by a bulk of evidence, are fundamentally open to scrutiny and can be disproven at any stage by someone who is willing to ask the question. This is science .. There should always be room for doubt and uncertainty, if there isn’t there is no growth and no one has any chance of improvement. If you look at it this way, uncertainty is actually an amazing positive, because it provides an opportunity for improvement, it allows growth.

So ultimately, the ‘quick fix’ is an empty promise, because you can’t be 100% sure that you did, in fact, cause the reduction in pain that your patient experiences – no one can be 100% sure of anything! It might just be that your intervention’s puny effect size may have added 10% to the general picture of a patient improving; I think being open to this possibility is not only important for our own growth as professionals, but importantly reinforces to the patient how much they did on their own. In a condition that is so inherently complex and uncertain as low back pain, there can be nothing more damaging than providing false absolutes of a quick fix or an easy cure based on your intervention. It creates a false dependence on something you likely have minimal control over. About the only thing that has a high probability in this condition, is that it will likely happen again once you get it and generally most people get it at some point in their lives (Ref). Patients need to understand that they need to be open to the possibility of it happening to them and returning once it does happen – this is the order of the natural world. Low back pain is complex – and like any complex problem – it is emergent without a possible direct prospective link to causation, meaning you may not be able to prevent it 100% of the time. It might just happen – it is a normal product of living in an unpredictable world.

If we absolutely have to get reductive at any point with our patients (which, let’s be honest, we will need to) what do we focus on?

Interventions generally have small to no effect size when all things are taken into account, so it is quite difficult, to pin down any intervention with a high probability of reducing disability and pain once you get it. Most systematic reviews, which pool together all interventions and provide a more representative picture of things that actually move the needle on a population level, come up with underwhelming conclusions for most interventions. Unfortunately, when I concede my own personal bias, even things like movement and advice to stay active are fairly underwhelming in terms of effect size and low back pain (Ref, Ref). So what are we to do?

Be honest and educate our patients that we don’t have the answer might be a start. It might be a start to admit that being reductive isn’t the solution, that there are probably multiple things that they need to begin working on to see any significant change. That is our challenge as professionals, to take the hard road and ensure the patient knows exactly how much they need to do and how little we are doing. And the patient needs to start the journey along the hard road to long-term behaviour change. We need to teach the capacity to not be afraid of the onset of pain (especially low back pain), because in the natural world, it is impossible to predict and if it does happen to our patients, there are probably multiple simple, but hard, things that they can do to reduce their symptoms and have a better life.

What we really need to do is teach and embrace uncertainty with patients. It is the antithesis of a ‘quick fix’, in that there is no guarantee – because there shouldn’t be in an unpredictable world – but that is ultimately a good thing, because it opens the door to improvement and growth. The best thing about teaching to embrace uncertainty is that it gives the power back to the patient – if they have control, they can ultimately change their life! Importantly, we – as clinicians – need to have the confidence to not have certainty about our interactions; a quick fix is nice to say, and sure makes everyone get the warm and fuzzies, but if you’re being really honest with yourself there is no guarantee in your ‘method’. Be scientific and embrace uncertainty, and maybe we will all improve together.