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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.

heisenberg-gray-t-shirt-textual-tees

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.

 

‘My physio bill’

Oxfam_11

Whilst on the Oxfam Trailwalker, I heard this phrase a couple of times, ‘my physio bill,’ in various contexts, like ‘mate, if you fart in my face again, I will personally make you responsible for my physio bill,’ or ‘remember that bet we made before we started where you said you would take care of my physio bill. Suck shit, mate’

Now I understand there are nuances to this and multiple levels of complexity, but it got me thinking about how the public perceives physiotherapy as a profession and is this at odds to what most good physiotherapists would want us to be perceived?

What do the public generally think about ‘their physio bill’?

Although some of us may be all too aware that the bill incurred by physiotherapy is nothing close to that of a surgeon or specialist, but it can obviously be enough to make someone bargain, bet or bully their mates with. It can be hefty enough to be something to offload.

Now you may be thinking the Oxfam Trailwalker is an extenuating circumstance; obviously the treatment bill would be ‘overs’ after something like that. I’d say, yes, you may be right, but I am more seeking some level of discussion in the normative case. When the ‘physio bill’ for young athletes becomes something to make mum and dad skip their date night for, when the ‘physio bill’ for the older couple after his second cortisone injection for the year failed causing them to forego the annual holiday to Port Macquarie. These are all too common occurrences, I’m sure you can think of similar situations that you’ve heard of, or embarrassingly – like me – may have even been a part of throughout your career.

So what am I getting at? I want to know why physiotherapists generally feel the need to bleed people dry to get an outcome. Now I don’t think we are as bad as other health professionals in this… you want me to name them don’t you.. well it begins with ch and rhymes with schmiropractor.. But seriously, physios aren’t that bad, but I think some elements of our training and the business model in which we are forced to practice, are really at odds with what the best evidence now tells us and how physiotherapists generally want to deal with things.

When pushed to extreme sleep deprivation and exhaustion the brain does some weird things; for me, as I rounded another bend and hopped over another rock at 5am, I started thinking rather existentially about the meaning the public puts on the physiotherapy service and it struck me as odd that it is pretty at-odds to what your everyday physiotherapist would like to consider her or himself as. I mean, do we want to be known as the professionals that:

a) are anything other than a necessity ? Once we lose the impact of our service, it gets devalued.

b) are providing anything but the maximal value? Once our service is seen to be low-value for money, they understandably bemoan the ‘ongoing treatment’.

Is it the providers?

Bleeding people dry is a strong term, so I may rephrase; why do (some) physiotherapists feel the need to prolong treatment and devalue our service? I have written about something I like to call the payment paradox in another blog here. There is good evidence for a host of barriers that prevent clinicians from adopting best practice and clinical guidelines (Ref). Lack of agreement, self-efficacy and an inability to overcome inertia of previous practice being some common reasons against change. And when you combine these legitimate reasons against changing behaviour with a reliance on low-value, passive modalities, what you get are clinicians who may just feel stuck with no knowledge or confidence to do different things. The shift toward using the things that we know work like advice, education and movement becomes an uphill battle; surely we can all empathise with that – it happens with nearly every patient we come across. Clinicians become very strongly attached to certain low-value treatments and when cognitive dissonance sets in, all of a sudden you have clinicians not just unable, but also unwilling to try anything else.

Screen Shot 2018-09-01 at 5.36.25 pm

How much of this can you actually blame on financial gain? I don’t know where the answer lies, but I know we all enter into this profession for the same thing – to change lives! There is a real shared altruistic bent to all in this profession and no-one really wants to actively hinder, or even harm, a patient for financial gain. Even the most sceptical of ‘Meakin-arians’ can’t believe that surely. Yes, maybe careless with language and lazy with professional development, but not malicious.

Professions like physiotherapy are marked by our relationships with the patient; generally they may end up meaning more to both parties than a good, speedy, efficient and value-filled outcome. It also helps that this relationship generally is rewarded financially, so it gets maintained and nutured so much so, that the break-up never happens. Cognitive dissonance is so strong that you may even end up losing sight of why the patient came into see you in the first place. This is not a bad thing, people – our patients – need crutches, they need a helping hand every once in a while when they are down. I’m not saying it is bad, but I am saying that crutches don’t get paid very well. The surgeon who fixes the leg, so that you don’t need a crutch anymore gets paid well. No, I’m not saying let’s all be surgeons… come on, I’ve got more sense than that.. I’m saying we all have the potential to fix the leg! Or at least make sure the leg doesn’t become dependent upon you. Why don’t we discharge more people!?

Instead of us being the ‘crutch’ who looks at the problem he/she can prop up and lean on – heck even maybe build a business on – we need to be a bit more like the surgeon, who looks at a problem she/he can fix, and discharge (yes, yes, the irony here is potent I know – remember I said, we are not going to all be surgeons),

So, where you may have some seriously unscrupulous practitioners, I think we have to look a little bit harder at the drivers. We have altruistic people, financially driven to look at patients not as people to be fixed, just people to be propped up until the next step in the road. Drivers, it’s about drivers.

So is it the model?

Yes, absolutely yes. If we increased our service fee it:

  • Allows all physiotherapists to provide maximal value at every appointment. This may result in people being seen less, but ultimately improves the perception of value in our service
  • Makes people take our service seriously, like almost to be a necessity – now wouldn’t that be nice!

Again, I know this is a complex issue with a lot of stakeholders, but if I can get a little bit reductive for a moment. The average fee for service has not increased in 30 years.. Why is that? Do we not, now provide a much superior service than we did 30 years ago?

To that end, a changing service fee would have people finishing the Oxfam Trailwalker saying, ‘I’m so glad I prepared the way I did and I don’t need to go to the physio again, it’s just not a luxury you know, it’s something that changed my life last time I went.’

I felt this way when I went to the psychologist and it really did change my life. It was expensive, but worth every cent.

So to conclude a short rant about something irrelevant loosely linked to an existential non-issue in physiotherapy.. Thanks for reading!

 

Strength and Conditioning; a new frontier in Workers Compensation?

I have some frustrations about the Workers Compensation (WC) system, it’s probably not hard to tell. In my team, we have highly qualified strength and conditioning (S&C) coaches working in a WC system and they have developed their own frustrations. We share some of the same frustrations, so this post is as much about them as it is me.

As a physiotherapist and level 2 strength coach, I think I’m fairly well positioned to comment on the matter BUT there are countless of other more highly qualified personnel that could, and no doubt want to, weigh in on this debate. Please do, but please respect my opinion as I respect yours.

For me, my journey in S&C started with an unimpressive rugby union career and like most physiotherapists it was cut short by injury, which promptly brought me to the dreaded long slow distance and triathlons; I got interested in being strong and resilient but obviously just wasn’t doing it well. What I realised after completing my first 3 -4 years of clinical practice was that when it came to prescribing exercise and progressing someone to performance, my university training had me woefully ill-equipped. While physiotherapy, as a profession, is leading the way in the allied health sphere when it comes to neuroscience, I honestly don’t think the same can be said about exercise therapy. S&Cs, increasingly, have to have tertiary level qualifications to begin their career. Generally in Exercise and Sports Science or similar; in fact in my experience, S&Cs sometimes have multiple tertiary qualifications (many gigs, won’t look at you unless you have a PhD) to their name before they really begin their paid career (before that internships are common). So, they are well versed in the basic sciences, just like any other professional.

Exercise Science is a degree (although I didn’t do it), that I think should be a pre-requisite for any profession in the musculoskeletal therapy realm. I would combine it with basic psychological theory and management, but that’s another story. It is a complex science that is should be the keystone of further training in the field. Because this still isn’t the general course for those entering a physiotherapy degree, then I don’t think we can call ourselves experts in exercise therapy. And those in glass houses shouldn’t throw stones. So now that I’ve laid bare my gaping inadequacies (now somewhat improved) in exercise therapy, we can move on to the point.

In musculoskeletal therapy, those people that should be termed experts in exercise therapy are the professionals who do this – and only this – day in and day out. A good analogy might be that you wouldn’t trust your GP to remove your wisdom teeth – on the surface that seems like a pretty simple procedure BUT let’s leave it to someone who does this day in and day out. We don’t expect it from other medical professions, so I think maintaining the same standards in allied health is important. Now I would accept that there are exceptions, as there almost always are. Generally, your sports physiotherapist, who has worked closely with the high-performance staff for years are exempt from this classification, as they have built an intimate knowledge of the complexities in loading and periodisation parameters. But your run of the mill generalist; to get real, targeted exercise therapy from this practitioner in a musculoskeletal condition would be a snowball’s chance in hell. Proper training and experience is needed, not just a side gig, in-between interferential sessions.

Although the Australian Strength and Conditioning Association (ASCA) are far behind in many aspects (we’ll get to that), it has remained true to its most successful element – the fact that to get anywhere in the profession, you need to have some runs on the board. S&C is a profession where the career pathway is experiential and that is important when it comes to exercise therapy. I have a bias and I will certainly admit that, but when it comes to a profession that requires intimate knowledge of exercise theory and concepts, I don’t know if you can trump S&C. In WC cases, exercise therapy is increasingly being preferred as the primary treatment option; so for pure ‘skin in the game’ factor, why wouldn’t S&C be considered?

Whilst there are similarly qualified professionals who deal in solely exercise therapy, namely Exercise Physiologists, they also suffer from lack of specificity. I’m not saying they aren’t going to do the job, and generally better than a physiotherapist, I am saying that in a discussion about specificity of exercise therapy in musculoskeletal populations, there are professionals who I consider of a higher order. And I’m not even saying that EPs shouldn’t have a large stake in Worker’s Compensation, because yet again, they probably create more active individuals than a physiotherapist (who also may have all the best intentions – but this patient is coming to a physio expecting some of those magic hands..), I’m simply saying that if you want to get this beaten up Hyundai and transform it into a Ferrari, I want to use the professional who knows how a Ferrari is made.

So, although there is a place for both professions, the crying shame currently, is that those professionals who have a very high level of knowledge, experience and clout in the S&C world are not even allowed to enter the playing field. I am not espousing that anyone with a level 1 or 2 ASCA should be WorkCover accredited, but I do think experience – ‘skin in the game’ – and level of knowledge in a relevant field (most S&Cs work in musculoskeletal settings with athletes in pain) should be recognised. I certainly think that if performing a role in settings where they do encounter the complexities of workcover should be accepted and further training be offered to upskill where necessary. I think of the training physiotherapists have to do to become workcover accredited – a dinky online test that takes 3 hours, which has nothing about exercise therapy in sight…. To understand the complexities of neurophysiological mechanisms and behavioural drivers of pain is probably not where I’d want my S&C providing primary treatment, but that is where physiotherapists excel and we can fill in the gaps.

Strength and Conditioning is not just for athletes or those wanting ‘high performance’

This is true but oh so poorly understood. Where does a S&C coach perform best? Where there is a close alignment (or sometimes not so close, depending on where you go) of physiotherapists and S&C staff ensuring all variables are accounted for and the desired outcome is achieved. The current model for WorkCover is world’s away from this; once the physiotherapist has butchered the exercise therapy and taken their time with the initial injury, then there is a very well demarcated gap between this and the ‘commencement’ of exercise therapy – performed by the EP. This leads to poor outcomes, frustrated patients and can be done better. More cohesion, more synergy is needed and having a profession that is used to working intimately alongside physiotherapy rather than in a separate silo is important.

The ASCA need to improve their game to get on the playing field

I think part of the ASCA’s lack of ability to set strategic plans in place for the direction of the profession is, in part, because it is such a young profession. Still finding it’s feet after only 50-odd years of mainstream, burgeoning, practice. But it is a worrying trend that there continues to be an explosion of ASCA qualified practitioners, without much checks or measures to what they can or can’t do after they get the ticket. I know the level 1 trained ‘high performance specialist’ who opens a ‘high performance facility’ really grinds the gears of my team and friends. More scrutiny around the pathway already developed is important, alongside firmer adherence to remuneration based on level of experience.

The ASCA are incredibly good at broadening their scope of practice and widening the reach of S&C as a whole. In progressing the profession, this will always be important. But legitimising the profession amongst the biomedical sphere is a weak point; just as the kind of role S&Cs can play is poorly understood – as above – the profession isn’t targeted to areas where it can make a big impact. And for me, this means talking about Workers Compensation. To make SIRA (governing body for Workers Compensation regulation) take notice and approve S&C to provide services, the ASCA need to make a concerted effort to lobby. I think it is a case that is hard to ignore. To allow appropriately experienced (say ASCA Level 2, on the pro-scheme and above) S&Cs, with access to the right training (pain sciences, online WC legislation training) to provide services under Workers Compensation just makes plain old sense in my opinion.

The ‘coach’ element

A key element, that leads to outcomes in my current team, is not just that I am fortunate to work with high performers, it is that our coaches have taken the ‘coach’ element to the next level. Yes, S&C is a science-driven profession (in terms of evidence-based profession, I must concede it is a way behind physiotherapy or even exercise physiology) but there is another gamet of skills the coach must have. The Art of Science of Building Buy-In by Brett Bartholomew is a great example of the emphasis placed on ‘soft skills’ by the profession. Building rapport, building buy-in, the art of the sell; whatever you want to call it, it is a skill that the coach takes pride in. You need to have this in order for the patient in front of you to truly come to a more positive frame in life. The WC system breeds a negative world-view and sometimes needs a ‘coach’ to bring someone through it. The aspect of the profession that guides and directs a patient in what is necessary and important in movement, exercise, attitudes, beliefs and pain is different to EP; less clinical, more connective. I think this works.

So, in the long-run, I think coaches will live prosperously alongside EPs in the WC world. It needs a bit of firming up of the pathway and training by the ASCA, more solid work on lobbying SIRA. But in the end, why deny this valuable skill set a chance to change lives in a very, very broken system?

 

 

 

‘Core Stability’; I call bullshit.

A guest post from Dave Renfrew of Newcastle Performance Physio

Before we get started, just some things to get out there first.

Things I am not saying include the following –

  1. “Core” exercises are bad
  2. Strong trunk muscles are a waste of time.
  3. People who run exercises classes or teach exercises based on the concept of “core stability” are dickheads
  4. Strengthening doesn’t help
  5. Pilates is shit
  6. Pain Science fixes everything

Right, I reckon that covers it. Let’s get started shall we?

Core stability, as a concept, is bullshit.

Ask anyone who is able to process a question and respond with an audible and discernible response and you will get an entirely different answer each time. Especially if that person is a health professional.

Answer it yourself. Now. Go. I’ll give you a few minutes.

…..

….

Right, what was your answer – BULLSHIT!!!! Ha, just joking.

You’ll normally use words like control, stabilise, protect, whatever. All of which give the impression of stiffness, immobility and the lack of variation in movement of which the back is capable, and actually really good at.

Let’s even just pause and remember for a second that there is no core. Where is your core? What is in it? Abdominal cavity? Does it include your back?

I get the idea. It’s in the middle.

Gymnasts and Surfers – bend themselves over into positions the rest of us are regularly told we shouldn’t do. Do they have good “core stability”?

What about if you lack “core stability”, do you have “core instability”? Bad things happen with unstable cores – like nuclear power plant bad. Is this what we are really saying?

So, let’s not say it.

The concept of core stability came out of research in the early 90s by Panjabi and friends here

The concept, while groundbreaking at the time, has since been shown to be oversimplified and based on incorrect assumptions. While it speaks of segmental spinal movement being associated with pain and injury, it also speaks of feedback mechanisms, central control and faulty firing and dampening reactions. This sounds more like non-human science right?

In Engineering, the stability of a system is also pretty complex, but is related to the relative relationship between input and output. An input, within a certain magnitude, results in an output also bound within a certain magnitude. Input and output are consistently linked, ie does it do what you want it to do. A stable system is also one which remains in a constant state unless acted on by an external stimulus, but then returns to that state once that stimulus is removed.

Stability in the spine is exactly the same. It is the consistency of its performance with varying inputs.

It does not mean DON’T MOVE.

Moving and instability aren’t the same thing.

Stability is not the lack of physical instability.

Stability is not about how strongly you can contract your abdominal muscles.

Now, as previously mentioned, I am not saying that doing these exercises is bad, stupid or whatever. There is evidence that learning to use certain muscles is extremely effective – postnatal pelvic floor and abdominal muscle activity for instance.

I am just trying to get you to think about what you are saying, thinking and why. The core stability concept was picked and run off with and hasn’t stopped to think if the game has changed.

A runner or weightlifter doesn’t need to do “core exercise”

People in pain don’t need to improve their “core stability”

Improving your “core” does not help with weight loss, athletic performance or pain relief.

Exercise can help with all of that. But there are lots of exercises that can do that. Exercise needs to be specific for the person and what they want to achieve. They do not need to be upside down on a BOSU ball trying to not move.

My definition is as follows – “Efficient load transmission between the upper and lower limb in the desired and specified direction and nature of your intended task for sufficient duration and at the desired level of intensity”. Try putting that in front of “..x..class” and selling it.

Which brings me to my next ranty point. Money and health. Always linked and not for everyone’s benefit. Now before you get all high and mighty again, i’ll say it first. I get paid for selling health services to people. I’m not saying people should do it for free, just that what they sell shouldn’t stink.

Health and fitness pick up on research, straw man the shit out of it, and sell it to the public on the basis of “if you don’t do this you will be fat”.

Tone your abs, Get core fit, Stability training, whatever they call it is generally boring, easy or a waste of time. I don’t care how many crunches you can do and neither does your back pain.

I am an advocate for exercise. Exercise is magic. We all need it, and harder and for longer than most people think. But misrepresentation of what people need to do and guilting them into doing it by making them feel inherently broken is bullshit. Saying every human needs to do a certain type of exercise is ridiculous.

The most important exercise to do is the one that will get done. There are generally 4 or 5 barriers to exercise

  1. Time
  2. Cost
  3. Access
  4. Enjoyment
  5. Pain/injury/problem

The best exercise to do is the hardest one possible that ticks as many boxes as you can.

I hate swimming. I am terrible at it and it bores me. I can swim to save my life (I think, let’s not test that out) and I can paddle with a board under me. But if you told me that swimming laps everyday would prolong my life from 85 to 105, i’d be smoking a fat cigar on the eve of my 85th birthday with a smile on my face. Not going to happen.

Swimming is patently good for you, cheap or free, relatively time efficient and we live in Newcastle FFS. Still, don’t care.

You do not need to do any exercise in particular. You do need to exercise. Hard.

Crunches may make your abs hurt, planks may make you want to throw up. But that just means you are getting better at ab crunches and planks.

I agree that if someone is not strong enough they can run into problems. But pain and injury are so much more complicated than a lack of “core stability”. It is a bullshit diagnosis.

The thing that most people lack is capacity. Load tolerance and ability to negotiate movement. We are sedentary, more overweight and doing less physically demanding things. That means we get worse at them over time.

Or we are coming back from an event that has decreased our capacity and we need to build some physical resilience.

Current recommendations sit at 300 minutes of moderate or 150 minutes of vigorous exercise a week with 2 resistance training/strengthening sessions. What percentage of the population hit that?

When we decide to get up and get moving things can hurt and get injured. That doesn’t mean that we have a “weak core”. It means that we have gotten crap at things because we are doing them less and our nervous system has decided that if we kept going bad things could happen.

The core stability model is too simplistic, makes people waste time on useless exercise and gives people false hope that because they can plank for a minute they are strong and healthy.

It is also very unhelpful for people that have been in pain for a long time.

Low back pain in particular is associated with an increase in hypervigilance, a process whereby, given the regularity and severity of pain, a person will either consciously or subconsciously “stabilise” or brace muscles in the back, pelvis, everywhere to make sure they are prepared for the upcoming task. But that could be picking up their toothbrush.

The constant overactivity is a big driver of neural signal to the central nervous system and can result in an increase in pain.

Imagine what happens when you tell that person that their core is weak, that they lack stability.

So what next then, Dave? Just whinge about how everyone is wrong??

For non health professionals.

Make exercise a priority. Do more of it, make it harder and continue until you die, or most likely you will die sooner than you need to.

If you are really strong and fit, well done, but stop putting images of your abs on social media. Old people like me think you are a wanker and young people feel they need to look like that.

If you find exercise hard, find what motivates you. For me, I have 3 young kids that are the reason I do anything. They currently think I am the biggest legend on the planet. I know this will change, but I want them to think i’m lame because i’m old and tell bad jokes and embarrass them, not because I can’t run around with them any more. The day i’m not their hero will break my heart and so i’m doing everything I can to make sure that won’t be my fault. Find what will make you do it and if you can’t –  ask for help.

For health and fitness professionals.

Adapt. We treat humans, the most adaptable thing on the planet. We live in a time where the best information is available at your FINGERTIPS. What a time to be alive!!

Get better. Realise that what you say to people has an effect. Learn more about what you do, all the time. No excuses.

Work together. Thinking that you are the only person that can help someone is ridiculous and often dangerous.

Exercise yourself you lazy buggers!!

Advocate for strengthening, exercise, self efficacy and increasing capacity at every possible point. Build Weapons of Mass Function capable of having greater influence on their own health and being role models for their descendants.

Recognise you will have biases towards what you like and what you are good at.

Exercise people however you want but make it about them, not you. Make them fantastic in what they want to do. Make their trunk strong, but make their legs strong, arms strong, make their coordination and speed fantastic. Give them good balance, agility and reactions.

And stop calling it core stability. It’s illogical and it pisses me off. Clearly.

Until next time.

Dave

What’s in a name? The problem with the diagnostic paradigm

Have you ever heard the expression, ‘If it seems too good to be true, it probably is.’

With respect to musculoskeletal medicine, the diagnostic paradigm has a stranglehold on the health system, but I’m going to put forward that it’s a paradigm that sometimes does not fit. Is it time we started to re-think our approach? In some contexts, does the diagnostic paradigm work against what we want to achieve?

Is the relative simplicity of the diagnostic process meant to reconcile something so exponentially complicated like musculoskeletal pain conditions? Can something so complex be boiled down by such simple ‘labels’?

Setting the scene

Like me, you may deal with patients attending with poor narratives, poor thinking and labels for the reason of their pain that they hold dear. It’s not as simple as blaming the label, of course, but one of the main reasons that hold patients back from a state of ‘action’ in dealing with a painful condition is the lack of an appropriate label or diagnosis. We’ve all seen it,

‘I’ve been to 5 specialists, 10 physios, a chiropractor, a naturopath, a horse-whisperer… no-one can tell me what’s wrong, everyone has given me a different diagnosis.’

This patient has been used and abused by the diagnostic paradigm, and is firmly stuck on the treadmill. Once again, it’s not always as simple as blaming the previous clinicians for being poor diagnosticians or that the patient has been just been given the incorrect diagnosis over time. Don’t get me wrong here, either, the skills of the diagnostic process (and here, I don’t mean our clinical reasoning process, because they aren’t actually the same thing) are important – integral even. And in my team, I can say we take pride in being excellent diagnosticians who generally deal with being ‘the last resort’ or a ‘tertiary referral centre’ amazingly. But in my team, we see predominantly Workcover cases; many of these are complex to begin with, made even more complex by the diagnostic process. It doesn’t seem to help these patients, in fact, it seems to hinder them. Searching for a diagnosis keeps them stuck. Another label is actually not the thing they need.

Having – or not having – a diagnosis is not the main issue preventing these complex patients from getting into an ‘action’ stage, it’s that the diagnostic paradigm has produced an unrealistic expectation. The system has told them that a label is exactly what they need to get better, and they come to trust this expectation. In some cases trying to fit a diagnosis on a painful condition is, as we all know, like trying to dress up a heaving wild boar. Sooner or later that pig is going to realise that its new clothes don’t really fit well and he/she would prefer to go and roll in the s*&!.

What are we doing when we diagnose?

“Diagnosis may be defined as the determination of the cause or nature of an illness by evaluation of the signs, symptoms and supportive tests in an individual patient. Diagnostic criteria are a set of signs, symptoms, and tests for use in routine clinical care to guide the care of individual patients.” Ref

Evaluating signs and symptoms using supportive tests to guide our care. That is at its simplest definition; it is a logical process and one that works fantastically well in other disciplines of medicine.

But are we doing something else when we diagnose? In a complex world with no absolutes, I think the use of diagnoses shouldn’t be so readily bandied by practitioners. Although some progressive specialists and practitioners actually can sit in the ‘grey’, the unfortunate world we live in dictates that the patient expects an absolute. They are conditioned to believe if they don’t have a diagnosis, then they can’t improve.

It’s complicated

Complicated is an understatement. If you think of a specific internal medicine specialty, the boundaries are fairly well established. There’s a general normative range. There are – at least a handful of – definitive tests.

In musculoskeletal medicine and pain conditions resulting from musculoskeletal sources there is the inherent complexity of the human being that is experiencing the pain. Then there are the multitude of tissues, sources, movement dysfunctions, control issues.. the list goes on. Pain drivers are wide and varied, this is a long complicated process to get across to a patient. The reductionist approach – providing a simple cause and effect model for a patient – does yourself, and definitely the patient, a disservice. It enables the ‘pill for every ill’ message to continue pushing forward, which in turn creates more doctor shopping and increasingly extreme treatment approaches.

Better education is needed throughout the system as a whole, we can all agree on that. That means this needs to start at the very beginning, with the diagnostic process; our education reflecting what is important about the process – the steps to improvements rather than the label itself.

It’s difficult

From the very simple – the bog standard knee meniscal tear – to the complex presentations, diagnosis is complicated.

I think we are all aware of the clinical shortcomings of physical tests for many presenting conditions, Thessaly’s, McMurray’s and Apeley’s all receiving about 50% accuracy when compared to MRI (the gold standard) (Ref). The same can be said about a more complex joint, the shoulder – the pathoanatomical approach is just horribly poorly performing.

In more obscure presentations, like fibromyalgia, the diagnosis is more like a crap-shoot (Ref). In cases like this, in particular, is another ‘label’ what this patient needs? Without this, won’t they still get best standard care?

The traditional approach

The pathoanatomical approach is the favoured approach by many. If you think this approach is completely appropriate in 100% of your patients, then do me a favour and just stop reading, like now…

It is useful, and I actually think the pendulum has swung very far away from this approach, to the detriment of many patients. I’d like to see the pendulum settle back and this approach is considered more useful. We all know pathoanatomy is found in asymptomatic patients, but something that irks me about using this argument to explain pain, is it includes a logical flaw based on information that you currently don’t have. You can’t prove that the pathoanatomy is NOT causing a patient’s pain, so saying it doesn’t play a role is sometimes a very inaccurate statement. The absence of proof is not the proof of absence.

Other approaches

We have exploratory work to create more relevant diagnostic systems. A great read into creating a movement system – or pathokinesiologic – diagnostic model by Ludewig and colleagues (here), is a step in the right direction. There are some tools and approaches designed to assist diagnosis (again, not to get confused with the clinical reasoning process). The pain and movement model can be used to educate patients but also provide a more multi-faceted approach to diagnosis. Neuro Orthopaedic Institute (I’ve always thought it such a misnomer??) approaches, as above, push the pendulum very far one way; this approach is very useful and is a far cry from the woefully inappropriate pathoanatomical approach but is it also too far gone to enable access to surgeons, GPs or those with a much more ‘biomedical’ background?

As for diagnostic classification systems, well, we have literally thousands of these relating to specific bodily regions. Based on region, duration of symptoms and irritability they are useful for communicating with other health professionals and third parties (like insurance companies), for research purposes and clinical practice guidelines.

It is all designed to categorise, label and make some pretty complex stuff fit into nice neat little boxes. Here’s the theme; it’s not that simple.

What do we do about it?

I think a few main approaches need to be explored:

  1. Being careful with exactly when and where a diagnosis is required. In absence of changing the diagnostic-curative paradigm and the system as a whole, we should consider placing a diagnosis on some people in the same light as other nocebos.
  2. Avoid chasing the diagnosis for a patient, for the above reasons and it will be another thing that holds them back from real behaviour change.
  3. A review of those who are in a position to diagnose and those who aren’t. The use of simply pathoanatomical labelling should be thought of as a risk to patients, and those that don’t have up-to-date training need to fulfil a requirement to do so.

This is incredibly important in compensable settings, where the only professionals legally allowed to give the most meaningful diagnosis are the ones with the least training in musculoskeletal diagnosis (GPs).

Please don’t mistake this post for a rail against the process of diagnosis, simply a discussion around its utility in the clinical environment and the musculoskeletal context as a whole. Because in a scenario where physiotherapists are the primary diagnosticians in compensable environments, I honestly don’t think the end result would be much more different. Those likely to ascribe poor meaning to a diagnosis (even if correct) would present with the same rumination, lack of action and negative beliefs.

Should it be given less value? I think so. Should it change form? In some cases, yes. In these cases, I think it is detrimental and a diagnosis should be labelled in the same fashion as any other nocebo. Just as our language around certain elements of practice has changed to avoid nocebo, our approach to traditional diagnoses should also change.

A re-think is needed in my opinion, a re-working of when and where a diagnosis is required. Buy-in from the system as a whole to ensure a simple ’cause and effect’ model is not always appropriate would be great. I think the most important thing to get right, is the knowledge and practice of when not to give a diagnosis and, if every stakeholder supports this decision, the patient can get on with the important thing – getting better.

Health literacy and predatory language

We’ve all heard of the dreaded nocebo, but when does the nocebo become willing use of language designed to hurt and mame for personal or company profit?

When does the average clinician become a predator? How much do you really know about your patient’s health literacy?

I witness a big push to stop unhelpful, damaging health messages amongst the top clinicians in my immediate circle. This is great and it would have me believe that predation in our healthcare system is slowly on the decline, but then again, I’m probably following and am friends with a skewed population group. Stories I hear from my team and the every day media forces me to remember that there is still widespread fear mongering and use of nocebic language. I contend that this kind of practice should be termed predatory behaviour and we still have an uphill battle to undo the widespread predation that is delivered by the system at large.

Health literacy; everybody’s duty

The World Health Organisation (WHO) defines health literacy as. “the cognitive and social skills, which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health” (Ref). This is fairly ethereal in terms of clinical practice; another definition from the US DoHHS, Healthy People 2010 report is “the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.”

So, you wouldn’t ask someone to squat their body weight if they didn’t have the capacity to get up from a chair. You would first assess their capacity in a task-specific format and tailor your intervention from there. I contend there is no difference between this and providing education and advice, an awareness of the individual’s capacity to take on-board, process and make a decision based on this information is critical.

Literacy rates in developing nations has a very strong correlation with birth rates and infant mortality and when women are more educated, they make more informed choices leading to population stabilisation and better infant health; do we need to start considering health literacy in the same fashion, a public health imperative in order to reduce our societal pain burden? Is it plausible that more informed choices about health, and specifically for readers of this blog, musculoskeletal pain conditions, would lead to better outcomes? Rhetorical question – I think we can all agree this kind of hypothesis is pretty sound.

Does the tidal wave of pain burden have a simple root cause in poor education? And by focusing on this on a wide-scale, can we change the course of one of today’s most pressing emerging health conditions?

Although good clinicians do generally present their information on an ad-hoc analysis of health literacy levels for each patient – it’s part of the most important job to do, to ensure your advice is taken on-board in the correct way – this is definitely not the case in interactions that can’t involve the same in-depth analysis. The all too common 5-minute GP consultation, the Dr Google search, the infomercial on daytime TV; examples of a health message that is at odds with the level of understanding and decision making capability are too many to count. I’m sure we can all think of these.

I’m sure I’m not alone in being exasperated by patients that attend with narratives that you think,

‘Where on earth did they pick that s&$! up!?’

Chances are, poor language – or health message from various source/s – plus poor health literacy combined, in a perfect storm to create the most almighty misinformation. Generally, nothing sinister, just mis-matched information for the level of capacity to understand in the first place. Although, we may sometimes see the intentional use of misinformation (I’m getting to that..) I don’t think actually happens in the majority of interactions.

Gauging the problem; assessing capacity

The problem is, that health literacy is a broad and complex issue – moreso than just literacy – as it includes the not just ability to read, write and comprehend but a social construct of active engagement of discussion with healthcare professionals. There is plenty of information on it online.

Various facets to health literacy include, but are not limited to:

  1. The functional level of health literacy: The basic skills of writing, reading and numeracy that allow an individual to function effectively with regards to their health.
  2. The interactive level of health literacy: A more advanced level of literacy, cognitive and social skills that make an individual capable of retrieving health information and active engage in dialogue/discussion with healthcare professionals.
  3. The critical level of health literacy: An advanced set of skills that includes critical analysis of health information retrieved independently or from the healthcare system and the ability to actively act on this information

There have been numerous attempts at providing a quantification for this concept.

  • The Rapid Estimate of Adult Learning in Medicine (REALM) is a chunky 66-item questionnaire, but a shorter 7-item version has recently been developed and validated (REALM-SF). This is most extensively used and validated in the US.
  • The Test of Functional Health Literacy in Adults (TOFHLA) has been validated across a range of populations including COPD.
  • Health Literacy Questionnaire is one attempt to comprehensively capture the concept, consisting of 9 domains. Produced in Australia by the Ophelia group, it is more relevant to the intrinsic dynamics of the clinical interaction. It can be dissected and tailored to your working population, I highly recommend having a look at this.
  • To make somewhat of a point as to the importance of health literacy, a very very large company has made it their business to gauge this issue. Pfizer, yes the very same company that essentially has a large stake in keeping people unhealthy, has produced the very quick and easy Newest Vital Sign. An ice-cream container label, consisting of 6 questions and takes 3 minutes to do….. I don’t even know where to start with the irony in this one, but you get the point, health literacy is obviously important.

The take home

I now work exclusively in the oh-so-worrisome Worker’s Compensation system. In this system, moreso than others in my opinion, a lack of health literacy is a contributing factor to poor outcomes. Yellow flags are compounded by a poor understanding of every piece of critical information that is provided. Where poor, and yes all too frequently nocebic, information is provided there is no proper processing and analysis of this information. In this way, nocebic effects are taken on board and transferred into a narrative that the patient will identify with. Unfortunately in the Worker’s Compensation system, this process of poor understanding of information, lack of filtering of ‘bad’ information and absence of any analytical thought is compounded by the patient being in a particularly vulnerable position. As the ‘pawn’ in a grand dance of powerful stakeholders – employer, insurance company and unscrupulous clinicians – they end up in a spiral into chronic pain, largely out of their control. A lot of this is due to the lack of basic skills in health literacy – the inability to make informed choices.

My take home is simple: before providing advice and education a crucial step is to assess capacity. Just as you would with any other intervention, get a baseline and progress accordingly. Otherwise you are as bad as ‘those clinicians‘; it’s everyone’s responsibility to upskill and educate every patient, improving public health literacy is a cause that we all have a stake in. The tool may not be the important point, but understanding that it is a broad and complex paradigm is.

Predatory language

Although the clinician may perform an assessment of the patient’s health literacy somewhat informally and ensure messages are tailored accordingly, I’m sure we can all think of clinicians that take an alternate approach.

That is why I propose using the term ‘predatory’ in the instances we see every day from various clinicians and platforms that we know are peddling harmful ‘fear-inducing’, nocebic messages.

The power imbalance in clinical practice is real and a very important concept to garner a full appreciation of. Physiotherapists are in a very uneven position and if you think it’s not as uneven as other professionals, then you’re wrong, it is every bit – if not more – as uneven. Patients are inherently vulnerable, and again, in my line of work they are made more vulnerable by being in pain and going through a compensable environment. This is where we see the Worker’s Compensation system fail again, through ensuring very vulnerable people are subject to potentially predatory behaviour.

Predatory behaviour is exhibited by parties, who are obviously more powerful than the average consumer – very large corporations in mass media is a good example of this. Dr Google, through the vey brief interactions that he/she has with A LOT of unsuspecting members of public, may be benefitting from pedalling adverts and ‘click-bait’ based on misinformation. Big Pharma benefit from a misinformed mass public, pedalling their products to people who just don’t know any better, like this advert for Lyrica in Fibromyalgia. An advert that spends more time listing the side-effects than actually explaining the effects can not be helpful, or understood well, surely?

Those in power who provide information without first assessing the capacity of the audience to understand and process the information should, in my opinion, be held responsible for more than they currently are.

Should we be more aware of predatory behaviour and be calling it out as such? As health professionals, isn’t this our first priority; a duty of care to our patients to ensure no harm can come to them?

 

Whatever happened to STarT Back?

If you didn’t know, Low Back Pain (LBP) is a condition that is crippling the current healthcare system. I have written extensively about this, and if a regular reader, you definitely already know.

LBP is the most burdensome musculoskeletal condition and consistently appears near the top of any health burden studies you may care to view. Surprising? Take a look and see.

Australian data:

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Global data: “in the Global Burden of Disease 2010 Study, LBP ranked highest in terms of disability (YLDs), and sixth in terms of overall burden (DALYs).”

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If you think your approach to LBP doesn’t really matter in the grand scheme of things, think again. Every single interaction with these patients contributes – in a positive or negative way – to this burden.

Although you may not be guilty of nocebo language and over-treatment, you can bet your bottom dollar (the accuracy of this statement will become clear later) that a lot of other physios and allied health practitioners are.

And so, to the crux of this instalment. I have also previously written about an approach to LBP, which is different. The Keele STarT back approach is one that, yes admittedly, have been indoctrinated into since very early on in my career, but for me makes perfect sense to attend for this immense health burden.

I don’t think it alters the whole picture, as I’ve said before, I think that will take a very widespread public health approach, which starts with thinking about pain differently. But it goes a long way to improve the care of people with new back pain now and who currently contribute to this burden. It doesn’t seem to be all that valid in those people with long-term back pain, so for this reason and more it doesn’t seem to be all that it is cracked up to be; let’s delve in!

What is the STarT Back screening tool?

  • The  Keele STarT Back Screening Tool (SBST) is a simple prognostic questionnaire that helps clinicians identify modifiable risk factors (biomedical, psychological and social) for back pain disability
    • The resulting score stratifies patients into low, medium or high risk categories
    • For each category there is a matched treatment package.
    • This approach has been shown to reduce back pain related disability and be cost-effective.

Keele_STarT_Back9_item-7

So, the STarT Back Screening Tool (SBT) makes it easy to identify those people with high levels of well-established psychosocial factors relating to poor clinical outcomes. In my opinion, any good practitioner should be able to identify these people any way, without using a tool. These people should be given the appropriate management and their ‘yellow flags’ should be up front and centre to that management. What this tool does do, however, is ‘filter’ people that will improve with little more than advice and put some metrics around those people that will require more intensive input.

This is where I think the SBT has its strengths; giving the clinician some objective data relating specifically to psychosocial cues and ensuring management is reduced to the bare minimum. Yes there’s a cost-effective element to this, but more important for me is the public health consequences. Less time with clinicians means less potential for nocebo and inappropriate treatment, less dependant patients, a minimally ‘curative’ and reactive system. These patients do not associate a resolution in back pain to the ‘treatment’ they have received, it empowers them to deal with another bout independently; heck, if you provide the right advice, they may even start to exercise and losing weight to reduce the risk of another bout returning!

Does it work?

In the UK, in its original effectiveness study, the tool was put to work in a huge population. It is a great read. A large cohort (n=851) RCT; including what I would say is a very representative sample of patients with LBP. My only issue with their chosen sample is the that they excluded people undergoing treatment for Axis-1 mental health disorders, because the incredibly prevalent mental health conditions we deal with on a day to day basis both adds to and complicates the overall LBP burden.

Through ensuring their approach to LBP management is based on a structured pathway, dictated by an initial risk stratification, they found a statistically significant difference between their intervention group and control group in disability, measured by the Roland-Morris Disability Questionnaire (RMDQ). The intervention group was also shown to have greater health benefit for a lower cost than the control group. They also found the intervention group had fewer days off work, which was most significant in the medium-risk group.

STarT back RMDQ

Their ‘intervention’ consisted of an initial appointment that included some specific advice about appropriate activity and return to work, shown a video called Get Back Active and given the Back Book. Low risk patients were only given this one session and told to go on their merry way. The medium and high risk groups were first given this initial session and then provided with care dictated by physiotherapists who were aware of their ‘risk group’.

Digging deeper, it is clear that both groups improved over time; you’d expect this in LBP as most cases improve with no other intervention other than the passage of old father time. But it seems stratification of care results in a measurable improvement in disability, overall. I’m a natural skeptic and this threw some questions for me; if it seems too good to be true, the chances are it is. So, in low risk groups there is no significant change in RMDQ scores at any follow-up; when someone is given nothing but advice and a couple of pamphlets, their improvement is on par with normal physiotherapy treatment. At the other end of scale, it seems knowing someone is of higher ‘risk’ may involve a more intensive approach by the physiotherapist and definitely does result in less disability.

Is this equation just self-serving? In so far as does it just reflect what happens in normal practice?

Certainly, in the public sector it is crucially important to ensure that resources are not wasted and the appropriate intervention is applied to a cost-effective end. Time is not wasted on those that will just get better anyway and those people needing most care receive it. So in the ‘ideal’ world, yes this is most definitely self-serving to demonstrate the best approach to utilisation of governmental dollars. But still, structuring this approach through the SBT isn’t such a bad thing.

It’s all in the context

Primary care settings have understandably become very interested in the tool and the approach. Adequate use of resources is of utmost importance.

The problems arise when time with patients equates to money in the bank as is the case in the private sector. And, in Australia, private sector clinicians are very much primary care clinicians for musculoskeletal disorders. Is this tool feasible in the private sector? Why haven’t we seen this researched in this setting?

Primary care physiotherapists in Germany are skeptical about the utility of this tool in different sectors precisely due to the inherent financial disincentives. Unfortunately, like my fantastic window-making German counterparts, I share this skepticism.

Is it reliable?

The tool has been applied in different countries across the globe. From Norway, Brasil and The (good old) United States.

study of 52 participants attending a primary care physiotherapy setting in Norway, found the SBT had good internal consistency and the stratification into higher risk groups correlated with higher levels of pain and disability. Pretty poor description of follow-up, and honestly, a pretty average study; generally I expect more of those Norwegians….

In the US a study of 1109 adults with acute non-specific LBP (non-work related), demonstrated that applying the SBT significantly predicted pain and disability levels.

Similar results have been found in Dutch and Danish populations.

In Brasil, they found applying the tool had most effect when applied after 6 weeks. This was in an Emergency Department setting.

So a lot of people are talking about it. For a reason.

The challenge

Can you do nothing? If in the private sector, this is the challenge. I don’t necessarily think this tool is the be all and end all, as stated above, it pretty much fulfils and structures the gold-standard approach. Do little in the patients that need little and do more about the important things in the patients that need a lot. The approach is the important point.

Can you do nothing?