Today, August 28th 2017, marks 2 years since the end of my physiotherapy schooling. In that time period I’ve seen a lot of interesting cases, had a lot of interesting professional opportunities, and had some ups & downs along the way.
In this piece I will detail what I’ve been doing differently during my last year of practice and cite some of the research behind those
1) Finding the line between not over-treating and not under-treating
Recent research over the last few years has shown that we as health professionals can overtreat patients and actually make them worse off. The two biggest examples of this in the literature are in Whiplash Associated Disorders (WAD) and in Low Back Pain (LBP) – two conditions that often get better on their own. Some research in Australia suggests that chronic LBP can be an iatrogenic (health care induced) disorder1 and that people with WAD who undergo a variety of treatment options are actually worse off2,3!!
Side note: both WAD and LBP are very heterogenous populations and some clinical populations (mainly WAD) can be complicated to treat due to the variety of other injuries and psychosocial changes that can accompany their main injury.
Finding the right level of treatment is a fine line. You don’t want to undertreat the patient and/or make them feel blown off & ignored … but you also don’t want to overtreat the patient and set them up for frailty.
When I find someone who I think will get likely get better on their own what I do is
- Educate them on a positive prognosis with their condition
- Give them some form of exercise/movement that they can tolerate as well as some self-management skills
- Minimize use of passive therapy
- Followup as needed and let nature take its course
2) Refining my subjective and objective assessments
One of my big gripes regarding “clinical reasoning” in the orthopedic physical therapy world is that much of it is based off of assessments that either lack reliability, validity, sensitivity and/or specificity and/or don’t correlate with pain.
That said clinical reasoning is still important to
1 – Ensure that musculoskeletal pain is the problem, not pain secondary to a major red flag that hasn’t been addressed AND
2 – Understand which pieces of the bio, psycho, and social are important to each individual’s pain experience
Lately I’ve tried to hack down my objective assessment and focus more on my subjective. I’ve said in previous years that, while I appreciate pain science, there initially wasn't a lot of information or guidance on how to practically apply it. However, in the last couple years some great resources have came out on patient interviewing and education through a biopsychosocial model. I encourage you check out the paper “Listening is therapy: Patient interviewing from a pain science perspective” for some practical tips on interviewing4. I don’t exactly follow this verbatim but it does help me a lot.
In addition I also use the Orebro Questionnaire to screen for psychosocial factors and maladaptive beliefs that may need to be addressed.
3) Using less core exercise & more general exercise for LBP.
A lot of research has came out over the last 5 years showing that “core-stability” exercises are no more superior to any other form of exercise for LBP5.
As I said above LBP is a heterogenous condition, and in my experience some people respond better to different types of exercise than others. I’ve had a client that did and didn’t tolerate each of flexion exercises, extension exercises, core exercises, walking, and cycling. While I don’t believe there is a magical exercise for LBP I’ve had too many people tell me that “the exercises my physio gave me made me worse” to believe exercise choice (and the reasoning behind it) doesn’t matter.
With that in mind – I have strived to use less core exercise for people with LBP (unless someone is a lifting junkie or has high occupational/sporting demands) and focus more on general exercise and importantly what the patient (where applicable) likes to do.
Tune back in 2 weeks where I will discuss 3 more changes I’ve made in my 2nd year out of PT school.
1. Lin IB, O’Sullivan PB, Coffin JA, Mak DB, Toussaint S, Straker LM. Disabling chronic low back pain as an iatrogenic disorder: a qualitative study in Aboriginal Australians. BMJ Open. 2013;3(4):e002654. doi:10.1136/bmjopen-2013-002654.
2. Skillgate E, Côté P, Cassidy JD, Boyle E, Carroll L, Holm LW. Effect of Early Intensive Care on Recovery From Whiplash-Associated Disorders: Results of a Population-Based Cohort Study. Arch Phys Med Rehabil. 2016;97(5):739-746. doi:10.1016/j.apmr.2015.12.028.
3. Carroll LJ, Ferrari R, Cassidy JD, Côté P. Coping and recovery in whiplash-associated disorders: early use of passive coping strategies is associated with slower recovery of neck pain and pain-related disability. Clin J Pain. 2014;30(1):1-8. doi:10.1097/AJP.0b013e3182869d50.
4. Diener I, Kargela M, Louw A. Listening is therapy: Patient interviewing from a pain science perspective. Physiother Theory Pract. 2016;32(5):356-367. doi:10.1080/09593985.2016.1194648.
5. Smith BE, Littlewood C, May S. An update of stabilisation exercises for low back pain: a systematic review with meta-analysis. BMC Musculoskelet Disord. 2014;15(1):416. doi:10.1186/1471-2474-15-416.