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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:

Screen Shot 2018-05-25 at 5.44.29 am

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?

The death of moderation

Yes, the title is fairly paradoxical, but what the hell happened to moderate health messages?

So I am kicking off a new instalment of this blog – Critical Health – with a fairly inflammatory statement about inflammatory statements.. Ironic!? Well, you just wait for the rest of the blog. Has the human predilection for dichotomous thinking gone too far in the social media age?

Sugar or meat? Meat or vegan? Sleep or everything else? Manual therapy or exercise? Surgery or no surgery?

As a physiotherapist, I will stick to topics I am most equipped to comment on, but I cannot sit idly by and write a blog about polarising health messages without getting into diet. Just make sure you fact-check the diet conversation. What follows is MY TAKE on debates (yes, I know, by nature dichotomous, but it doesn’t mean the answer is one or the other in ‘real-life’!) that rage within the current climate, which I have most trouble with. If you have some of your own, please let us know!

The pendulum will always swing, and by in-large, whilst an argument rages it will have to be pushed forwards by two opposing and extreme view-points until it eventually settles somewhere in the middle. BUT in the age of Instagram, Facebook and Twitter, these arguments are played out on a world-stage and the uneducated followers are misinformed and misguided, being lead to believe the answer lays at one ‘pole’ or the other. All the while particular camps’ viewpoints are being monetised and ingrained into public opinion.

Just because you only have 140 characters (now 280), doesn’t mean you have to peddle a completely unconsidered opinion. And as a staunch moderate, the lack of consideration, finer details and nuanced viewpoints in today’s arguments really grinds my gears.

Manual therapy versus exercise?

One of the most polarising debates out there in the physiotherapy specific sphere. Is the time spent on manual therapy completely unfruitful, detrimental and of no value in the treatment paradigm? Should physiotherapist identify as a profession who place little to no value on manual therapy?

I’ve written about this previously, and my views are well summarised by the phrase; do we need to identify as either a ‘manual therapist’ or a ‘physiotherapist who uses exercise’? If both are used in conjunction, and therapists wield the two approaches with skill and restrain, then this can surely enable a ‘complete’ practitioner. A practitioner who is capable of managing expectations and then able to provide the empowering, active approach that will ultimately ensure that patient changes their behaviour. Situations wherein manual therapy will actually be detrimental to improvement are easier to imagine for the clinicians, but I’m sure you can think of alternate situations where exercise therapy isn’t appropriate either. Are manual therapy and exercise therapy mutually exclusive in physiotherapy? No, and I don’t think most physiotherapists actually practice this way. But what’s more, I don’t think that it is beneficial to push a extreme view on this one.

Yes, manual therapy is a treatment with a lower proposed physiological effect over a long term, but it actually has good efficacy in short term pain relief and a lot of landmark Cochrane Reviews include some fairly old and low quality studies.  Similarly, if exercise is wielded in a fashion that does not promote self management and reinforces the reactive, curative paradigm, then surely this is just as inappropriate. I don’t know if it’s manual therapy that we should be blaming, instead the paradigm that goes along with it; one that is based on a reward system for being in pain and the monetisation of a public health burden.

How about we all just identify as ‘physiotherapists’ with a well-rounded skill-set.

Surgery versus no surgery?

There is a mounting evidence base to demonstrate sham surgery is as effective as real surgery; among a few are positive outcomes in meniscal tears, discogenic back pain and SLAP lesions that doing nothing but opening the skin and closing again can be as effective as removing or repairing the proposed pathoanatomical abnormality in the first place. This has spurred on a fairly vocal camp of supporters against any surgical intervention. There are, however, certainly some conditions, where the evidence points to surgery being successful; shoulder osteoarthritis is one, but knee ostoarthritis does not seem to be in the same catgeory.

In defence of surgery for the above conditions, there can be a lot of indications for a patient benefitting from surgery over conservative care. There may be some harm to be caused if surgery is delayed in certain cases, and although the debate about the overall utility of surgery in homogenous conditions is very healthy, painting everyone with the same brush isn’t healthy. Nuance.. what is needed is nuance.

Meat or vegan?

Being a dietitian would be a rough gig. These particular dogmatic, bi-partisan debates seem to be very much more commonplace in dietetics than other allied health fields. One of my personal favourites; should you cut out all meat and animal products or blindly consume all manner of animal products to the detriment of your health and the environment? Now I have no doubt that current practices and market forces in livestock farming have been horrendous for the environment. You can’t deny statistics like 36% of the world’s crop land being used for animal feed NOT human food, and this proportion sky rockets in developed nations – see here. And over 15,000 of the world’s scientists have officially issued a strong warning that if these farming and diet practices continue, we will be headed for environmental catastrophe. The WHO endorsement of red meat causing cancer was an almighty media storm in 2015, and rightly so, this link has been pretty well established in the research for years. Not to mention there are a myriad of reasons that the vegan diet is adopted on ethical, moral, psychological and somatic bases.

But, I just don’t understand why a diet reduced in meat and other animal products, world-over, in other words a plant-based diet is not the logical choice for everyone? We still get our protein, and when consumed only on a seldom basis it would be appreciated more and much higher quality. I’m heavily influenced by Michael Pollan in this argument, I think you should be too. For more information, watch ‘In Defence Of Food’ on Netflix.. Yes, my first big of 2018 includes a reference to Netflix.

Well there you have it, the first in more bite-sized blogs. I wanted to dissect more arguments, but there’s plenty of time to get into that. So, to conclude, the moderate message is an important one – tending to be the place where the ‘pendulum’ will land – but unfortunately is getting harder and harder to find nowadays. Let’s bring the moderate message back into the limelight, 280 characters on moderation and nuance – go!

Thanks and moving on..

ChuckNorristhumbsup Emil PI’m going to start this, my first post of 2018, by thanking the people who helped me get some content over the line in 2017; thank you all of my most esteemed, learned and brilliant colleagues! Although this blog evidently has a small readership, I’ve enjoyed the process of writing more than anything else. Collaborating and learning from others has been a massive bonus on top of everything.

The ultimate aim to this blog was to begin the process of writing and broaching some individual fears and barriers for me – putting out content for everyone to judge. In that small aim, it has been a success. Some failures have been the consistency with which I’ve written in 2017; it has been pretty random and I was not able to complete some content that I was most interested to put out. Namely;

  • Ditch the plinth bro’
  • Specialisation and titling; where is the profession leading us?’
  • Triple M and evidence based practice; gurus, senseis, and the average physio’
  • ‘Open letter to the APA’

These topics will hopefully be reincarnated in some form in the coming year. For now, I only want to thank those involved who helped me get the fairly unimpressive 14 blogs that I got out; hopefully I’m going by the quality over quantity mantra. All in the growing process..

Moving on..

As I move to a non-clinical leadership position, I’m forced to recall a lot of friends who have also left clinical roles; at the far end of spectrum a lot of friends have left the profession entirely. It seems a lot of physiotherapists do it at some stage. It is obviously prevalent in other professions, but a recent look at Australian physiotherapy registration data may tell an ominous tale for us; after the age of 40 the registration rates are 46% of those in the age group 25-29 (Ref). This, of course, is just one way to look at the data. You could also look into this as a profession that has gone from 23,300 registrants to over 30,000 in five years and proportionally those under 40 years of age remain about 60% of the profession whilst those over 40 years of age remain about 40% from 2012 to 2017. We have remained a young profession, on the whole, and maybe this can’t be looked at too much further without reviewing some causative data.

And so in this chapter of my life, I have to say maybe I’m not that special or unique. Is this a deeper sign of widespread frustration at the profession as a whole?

I’ve alluded to some intermittent frustration at the profession throughout my (albeit expressly ‘mid-range’ career length; so judge this as you please) career (Ref), and some might say this is just another ‘generation Y’ aiming for things that are unrealistic or buying into a sense of entitlement. I do think that some of what has pushed my friends out of the door of this profession must be narratives in a lot of physiotherapists’ careers; hell I even see these deep undertones in the most popular of blogs. What exactly is in this frustration?

Moving on Jan 2018 post

Is it lack of responsibility?

The glass ceiling is low and that is a product of a few things in the physiotherapy profession. A lack of firm prescribing, imaging and referral rights produce a lot of frustration for mid-career physiotherapists like me and something I have written about before. But there is merit to the counter-argument that we should improve our internal practices before we branch into more responsibility in the medical system.

So, to follow this argument, Physiotherapy’s constant internal review is a real strength and only serves to improve what we already do. But it does tend to add to a sort of sense of nihilism about Physiotherapy’s capacity to improve any condition that most physiotherapists see on a day to day basis.

Is ‘physio-bashing’ hurting the profession?

Moving toward a very strong evidence informed practice has pushed a lot of what made the practice of Physiotherapy, ‘Physiotherapy‘ into the world of anecdotal and unsubstantiated ‘guru-ism’. It has brought doubt into a lot of pre-existing practices but also thrown a lot of commonplace practice under the bus. Simple is best, and there may be some overly complicated practices that are nothing better than placebo remaining in the backbone of our profession.

Although this sounds very doom and gloom, I think it will only ever serve to make Physiotherapy a profession that is honest and confident enough in its practice to have such a strong critically reflective cohort. In fact, much of medicine suffers from the same scrutiny; we – as physiotherapists – practice some of the best evidence based practice. Non-specific effects dominate any treatment scenario and it is the awareness of these that will specific effects to be used more efficiently. Better evidence and reflection on the practices that involve a lot of non-specific effects – like manual therapy – will also improve the efficacy of their use.

Therein, I think the profession is healthier now than it ever has been and most likely the minority of those who leave the profession during their career will possibly even strengthen it to ensure those that are left are practising and adhering to the strong evidence informed models that are continually improved. So, while a sense of nihilism comes along with ‘Physiotherapy-bashing’, it’s actually a very healthy component of Physiotherapy.

Is it a career thing?

The options remain limited at the top of our profession, and I will make no bones about this being a limiting factor for myself. But as things improve I know he structure for mid-career physiotherapists will similarly improve; otherwise we are going to have a lot of masters-level qualified physiotherapists with not much else to show for it other than a piece of paper on the wall.

What this comes down to for me is the definition of a career-path; in most other professions it is very clearly depicted, but with physiotherapy it is muddy and seems to have too many avenues.

Is it burn-out?

I looked into this; empathy burn out for physiotherapists has been documented (Ref). Don’t get me wrong here, I think the very fact that physiotherapists spend more time with each patient is one of the defining facets of the outcomes we are able to have; positive outcomes happen in large part because most physios invest so much time and effort into each patient. But this time takes its toll; more time engrossed in all of the complexities that painful conditions bring with them. Emotional exhaustion has to be high with all of that time dealing with complex patients and unrealistic expectations.

Each physiotherapists takes part in the ‘fun-park’ of pain with every patient, some to a higher degree than others. And here is the important part:

Physiotherapists want to help people, a lot of mid-career physios want to fix people. For the physiotherapists that deal with musculoskeletal pain, this is a condition that is so complex, so intertwined in every patient’s very fabric of being, that it is a fool’s errand to fix. Pain is a waxing and waning phenomenon throughout life, a lot of what we see clinically is simply regression to the mean and I think the best job a physiotherapist can do is to identify those people that are likely to cause a larger burden on health systems (by becoming chronic), and ensure that no nocebos are given. Those patients are treated with carefully constructed language to ensure that they don’t return – even for another problem – worse than the first time. 

So, maybe it is this fact that burns out some physiotherapists; a slow steady realisation of this. I know I have had these thoughts, or maybe I suffer from the same unrealistic expectations as my patients.

To conclude..

So, if you have recently ‘hung the boots up’ I want to hear from you; if by choice, what were your reasons for leaving the profession?

I’m still hanging around, even if I’m in a ‘paper-pushing’.. sorry, leadership role.. I’m aware of the limitations and considering them this year with a cautious eye.

Compliance

The eternal struggle for outcomes in physiotherapy is in large part due to compliance, or lack thereof. I’m going to break this concept down and attempt to arrive at some strategies. Non-compliance for exercise in physiotherapy has reported to be as high as 70% (Ref). Personally, I always knew compliance rates in physiotherapy were low, but to think it could be as low as 30% for any HEP is quite sobering. Of course, it is not so cut and dry as there are many nuances and intricacies in the massive issue of treatment adherence and by no means is physiotherapy alone in low compliance rates. But I would like to hazard a guess, that if not ‘sold’ well, compliance rates can be much higher than 70%.

So why so low?

A systematic review by Jack et al in 2010 (Ref) outlined factors affecting barriers to treatment adherence in physiotherapy outpatient clinics, these will seem obvious to the clinician, but appropriately researched (all cohorts, however):

High levels of pain:  I think physios are already pretty damn good at understanding patient’s experiences and beliefs about pain. It is one of the central tenants of our profession to challenge mal-adaptive responses to pain, so in this barrier, physiotherapists are already doing enough.
– Low levels of physical activity (PA): Again, this would seem like common-sense to the tuned in practitioner but in particular some interesting issues include poor programme organisation and leadership and poor education. Issues like poor history of exercise, perceived physical frailty, perceived poor health and readiness to change are other barriers to change, which make a fair bit of sense.
– Self-efficacy: If your patients have low confidence in your ability to undertake the exercises prescribed they will hardly go out of their way to actually do them. Again, this is something I think is done quite poorly; explained in the clinic on paper but never actually demonstrated and confronting patient’s low self-efficacy levels.
– Depression, anxiety & helplessness: Something that impacts on the entire picture of treatment of someone coming to the clinic, and something that should be at the forefront of ‘tackling’ as soon as possible.
 Low levels of social activity
– Patient’s perception of barriers to exercise: Now I think this can entail everything like, oh, say, the entirety of life, so in reality this is HUGE! So every time you hear, ‘I couldn’t do my exercises because I couldn’t find 5 minutes between walking from my desk at work to the printer,’ this is a perception thing, even though you have sold the ‘exercise thing’ phenomenally and removed seemingly every single barrier possible. I think this relates to the (transtheoretical) stage of change they are currently in and there are there are obviously other nuances here that complicate these perceptions (like depression, anxiety and helplessness above). There is evidence that implementing coping plans may help patients to overcome difficulties (Ref), but there are other strategies that may be of benefit that I will outline below.

In a newer systematic review, Beinart et al 2013 (Ref) (11 RCTs and 3 cohorts), outlined that distress levels, whether higher or lower were not overly associated with adherence in chronic low back pain patients. Higher pain levels were very weakly associated with lower adherence and the same can be said for disability levels.

So what can be done?

1. Communication is key. 

Lonsdale et al 2017 (Ref) performed a large (n=308) well-designed RCT across multiple centres in Ireland. 50 physios delivered either a control intervention consisting of standard care for chronic low back pain patients or the treatment intervention, which consisted of motivational interviewing techniques designed to upgrade adherence. More on these techniques can be found here.  When physiotherapists were trained in communication to increase adherence in 2 main (related) theoretical realms:

  • Self-determination theory
  • Motivation Interviewing techniques: the 5As. See more here.

This was shown to improve patient-reported adherence (not pain), but these were not maintained into 6 months. I think this small effect size is actually pretty encouraging given the HUMUNGOUS issue of behavioural change and this trial probably needs rolled out among a larger cohort. Communication, is the main tool of the health professional, and if used to address the factors listed above as ‘barriers’, then this is the best start to any outcome.

2. Building motivation to exercise

Chan et al 2009 (Ref) , designed a retrospective cohort (n=115), where participants were asked to recall their experience of ACL rehab and using algorithms they determined a level of therapist ‘autonomy-supportive’ behaviour; they demonstrated that when therapist behaviour was more autonomy-supportive, this had increased effect on motivation and subsequently (apparently adherence).

Beinart’s systematic review demonstrated that only one individual patient factor had moderate evidence to be associated with adherence:

  • Higher health locus of control.

This fits with the above in so far as building motivation is linked to increasing self-efficacy and perceived control over their improvement. Higher motivation was associated with adherence to exercise, but had limited support and those with a stronger belief that others had control over their back pain exercised significantly less (Ref).

The above points demonstrate, that building intrinsic motivation to exercise in individuals, increases self-efficacy and gives the individual a perception that they can actually do some exercise. Herein, lies the crux of it; if you tell them they can do it, they may actually do some activity, and THEN they may do some of your home exercises as well! Halleluyah!

3. Supervision

Supervision has been shown to be a very positive factor in improving exercise adherence (Ref Ref ). I think this has been pretty well understood for a while, it generally crops up in most large reviews for any treatment intervention, and I am remiss to even mention this as the general gist of this post is to explore factors related to exercises you prescribe for patients when you can’t watch them, but this is important; supervise your patients doing their exercises, if only for a wee bit. It helps.


4. The art of the sell

If you can sell your program, and I mean really sell it, not just ‘promote’ it, then you can project an increase in uptake. I think more physiotherapists do need to understand more sales principles, we are a profession that has always been behind other professions like chiropractors and osteopaths in ‘the art of the deal’. And in turn, if more physios can use good sales technique, spend less time selling an individual treatment and more time selling self-management; well that seems like a world-changing idea to me. And in case you didn’t guess, no I don’t mean be more like Donald Trump; if we all did that the world will change for the absolute worst; just maybe sell the shit out your wares like only Trumpo knows best.

5. Periodisation

I think this is very underutilised; as an S&C I have the benefit of seeing things from two professional backgrounds. Physiotherapists are again, typically very poor at periodisation. Periodisation is the cycling of various aspects of a training program, or exercise regime. In S&C, variation of exercises, load, volume etc. etc. etc. is the key component to optimal physical performance; physiotherapists generally produce a horribly repetitive linear progressive overload with not much extra stimulus for the patient. If patients were exposed to more principles of periodisation in their home exercise programs, they would remain more interested and the ‘learning effect’ from mastering one exercise which links to their problematic movement, would cross over into their overall pain issue and promote more self-efficacy. For example when prescribing for shoulder pain with trouble through forward flexion and horizontal push patterns programming scapular push-ups is great, but periodising not only the sets and reps over your rehab program will help maintain motivation, but accessory exercises – like a cable paloff press – will help challenge the neural control mechanisms and enhance capacity in the movement.

Compliance; one of the biggest issues facing the musculoskeletal chronic pain burden on society. Inherently really very difficult to achieve for any treatment, but physiotherapy is evidently abysmal at it. So try more strategies, but remember, communication is key and motivation is king. ​

Leadership in Healthcare

leadership in healthcare

It is time to step up; we’ve all got to become leaders.
 
A topic that makes a lot of people very passionate, but particularly me. This is written from a perspective of a clinician with an awareness of the inadequacies of the healthcare system but also the profession in general.

Physiotherapy, as a profession, is in a wonderful position to truly lead the health system out of the curative, illness-sustaining model and into a new preventative, wellness-promoting model. This system, that is designed to keep people unhealthy, is also designed to keep people in pain; and until things change chronic pain will continue to be a massive burden on today’s society. I think allied health, in general, can become a leading field to change the public’s perception about musculoskeletal pain but I can focus on physiotherapy as it is my field of knowledge; if you can extend this to your own practice in another field, let me know!

A good definition of leadership is (Ref),

‘a social influence process through which emergent coordination (involving social order) and change (i.e. new values, attitudes, approaches, behaviours, etc) are constructed and produced’

Traditional leadership theories are underpinned by the explicit and implicit qualities of leaders. The issue with this approach is it tends to undervalue a few things and overvalues the power of the ‘position’ of being a leader (Ref). Some of the things that traditional theory undervalue are:

  • The process of leadership; it is a fluid, interactive process.
  • The complex dynamics between parties; in complex systems like healthcare, unfortunately reductionist thinking leads to missed opportunities for progress. If taken for what it is, healthcare needs to learn from all parties to stimulate change and growth.
  • Innovation; traditional leadership, is concerned with values and position, by virtue of being concrete do not align with innovation and change.

The position of leadership that we find ourselves, as clinicians, is the ultimate leverage to influence change. I think there is a world of untapped potential and the intricacies of leadership should be demonstrated more in clinical interactions to produce better outcomes. This means the position of leadership is taken for what it is, but also the process of leadership is promoted amongst the profession (and allied health in general), in order to effect change. So I’ve listed 5 key areas for enhancing leadership in every clinical scenario, which, in my opinion should become the basis for driving outcomes towards a better system and healthier population.

1. Every encounter is an opportunity to show leadership.
As may be evident from the introduction, every single time you interact with a patient, you are being given opportunities to lead. No one else is going to lead the ship, and the patient has given you implicit permission to lead them through their injury/rehabilitation/psychosocial issues/unhelpful beliefs, so step up and lead, it is that simple. There are enough great resources out there to enhance your skills for treatment, and it is the duty of every health professional to stay abreast of the evidence. But clinical treatment is about more than evidence-based or evidence-informed decision making; leadership, in my view is a massive missing element.

2.  Leadership is a two-way process, so take your cues from the patient.
Traditional theory explains leadership as a dyadic relationship, and for the most part, when referring to clinical management this is true. It is mostly a relationship between two people looking to effect change. But it is not a one-way street; effective leadership is understanding the nuances of promoting intrinsic motivation. This means listening to the patient and responding to their cues; sometimes they want to demonstrate leadership, and sometimes they will be asking for leadership from you. Take these and ‘guide the ship to the destination’.

3. Communication is key.
A good friend/mentor of mine is known to say, ‘everything in life rises and falls on leadership and leadership rises and falls on communication.’ It is pretty evident that communication is key in our professions, but in some scenarios if we really listen and take cues from both the verbal and non-verbal communication we are receiving, we can have the biggest influence.

4. Great expectations… it’s about challenging, not just meeting, expectations.
Meeting patient expectations has been extensively written about in this and other blogs. Part of the reason the Western world finds itself in a position where musculoskeletal pain has become one of the most burdensome conditions is that expectations have simply been met. Too many clinicians have foregone a leadership role and public expectations are met and not challenged. For me, the best clinicians, challenge expectations and demonstrate leadership in everything they do. If more of us are willing to do this, then maybe there is a way out of this mess. If we are taking cues from the patient and remaining aligned with their values then these challenges can result in permanent and important change.

5. Bring everyone into your leadership circle.
In clinical scenarios sometimes this may involve asking other professionals around you to show more leadership. In a complex system like the healthcare system, too much focus has been placed on individual leadership for too long, to the detriment of the public (Ref). We need to make it our mission to raise those around us to change outcomes, not just perpetuate the same outcomes. Importantly, this involves the biggest stakeholder; the patients themselves! Asking our patients to become leaders and continue to challenge the system around them, will develop more resilient humans, who are ready to forge new paths out of pain and into health and wellbeing.

Our ultimate aim, as health professionals, is to obtain better outcomes for all patients and create social value by enhancing quality of life, promoting health and returning patients back to wellbeing. So to me, this means we all need to step up and begin to develop our own individual leadership capacity and demonstrate this with each and every patient. On top of this, asking those around you to do the same, and asking the patient to demonstrate some leadership of their own will be an important step to reversing health trends that have continued unabated for the last 20 years (Ref).

If you have any thoughts, please share them, and thanks for reading.