Are we all the same? Are we all different? Are we all the same but different? I’ve been thinking about this a lot lately and my current opinion, take it or leave it, is that the bulk of what we fight over and spend so much time studying are small things that just don’t really matter all that much in the grand scheme of patient care.
After a lot of contemplation, some painful growth, some excruciating feedback, and long looks in the mirror, I’m confident that if we could zoom out a bit, we might just be able to temper our egos, see the forest, and actually help a lot more people. I’m convinced that (and quite a bit of data on acute neck pain, low back pain, and shoulder pain) 60-70% of people we see in clinic will get better with most anything we throw at them as long as it involves a little bit of movement, a little bit of symptom modification, a good relationship, some time, and a lot of natural healing.
We need to get over our ego and false sense of “badass-ness” that’s based off of this over inflated batting average. The “other 30-40%, the people who don’t get better, the people for who pain is complex, the people who have lifestyle factors that need to be addressed, the people on the medical round robin, the people who have been on the symptom modification merry go round for years, the people who have lost hope, the people we have consistently blamed for not getting better in the past, these are the people we need to focus our attention on. Despite all these improvements in modern medicine. Despite all of our fancy techniques. Despite all of our doctoral degree. This group of people is growing. Chronic pain rates are steadily increasing. Expenditures on chronic pain are skyrocketing. Yet, we are bickering over minutia.
We have so many different “best treatment approach since sliced bread” factions in the rehab world. All of these different approaches seem to claim to get great results, better results than anyone else, and “always get their patients better”.
“I do mobilizations and get great outcomes!”
“I do manipulations and patients love it!”
“Fascial release is the treatment most therapists are missing to become more effective!”
“Deep tissue massage and trigger point release usually work the best from what I’ve seen!”
“I’ve seen the best outcomes with scraping!”
“Really, the thing you’re missing from your toolbox that seems to work for me is taping!”
“I can’t believe you do all that passive care, don’t you know that you need to load it!”
“How do expect people to get better when they don’t know their pain is like an alarm system? You’ve got to PNE it!”
“I get the best pain relief from my patients when I perform acupuncture a distal and local points!”
“Really, if you aren’t doing dry needling you are missing the most powerful intervention we have available!”
Manual therapists, pain science people, muscle meatheads, joint jockeys, fascia fellas, trigger point pinheads, load it lads, functional freaks, posture pimps etc, etc. We all seem to get patients better and bicker about who and what is better, yet when we look at studies comparing effectiveness, we are often fighting over differences that don’t even achieve clinical significance.
We argue over studies that show a difference of 0.5-1.5 on the NPRS, yet ignore the fact these studies don’t blind patients, can’t blind therapists, don’t measure equipoise, don’t take into account patient expectations, ignore meaning response, aren’t pragmatically designed, don’t have true control groups, have single outliers that skew means, and a whole host of other factors that could very easily account for every bit of that 0.5-1.5 point difference.
If we just take MT for back pain in general and take look to the Cochrane database, we see their conclusions “SMT is no more effective in participants with acute low-back pain than inert interventions, sham SMT, or when added to another intervention. SMT also appears to be no better than other recommended therapies”. If we look again at the Cochrane database on MT as it relates to chronic back pain, we again see “High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain.” If these findings don’t even show much benefit at all, why are we bickering over which flavor is better. All the while ignoring the more likely reality that it’s subjective and all falls back to patient and clinician biases.
Low back pain follows similar trajectories regardless of intervention
Interestingly enough, if we take a gander at a study published by Artus in 2010 (graphic below), we can gain a deeper appreciation for the natural course of back pain across a wide variety of passive, active, and wait and see approaches. The main aim of this review was to summarize evidence on responses to treatment among low back pain patients in clinical trials in order to test the hypothesis that these responses follow a similar pattern regardless of the treatment used.
The authors go on to state they found evidence that the responses in all studies seem to follow a common trend of early rapid improvement in symptoms that slows down and reaches a plateau 6 months after the start of treatment, although the size of response varied widely. They found a similar pattern of improvement in symptoms following any treatment, regardless of whether it was index, active comparator, usual care or placebo treatment. The authors then discuss in detail many factors they may explain the treatment outcomes such as the intervention itself (specific effect), non-specific factors, random variation, and errors in the trial design or analysis. In the conclusions, they come away with the answer depicted below:
So this begs the question; If everything works, does that mean nothing works? If all of our outcomes are about the same, is it that every technique works, or should we be looking at the common thread that strings all of our infinitely variable patient interactions together?
Where do we go from here?
So what do we do? Do we just throw our hands up? Do we just give up and say we are worthless?
No, not at all. I’m cynical, but I’m certainly not that pessimistic. I just see the potential that we have and am tired of the countless hours spent on pointless discussions centered around the minutia of whose guru technique imparts the largest non-clinically significant effect despite the mounds of evidence that point to equivocal outcomes and paint the picture of pain that is so much bigger than what is going on under the tips of your fingers. I’m tired of the focus on outdated, overly simplistic, and less than accurate core curricula that focuses on biomedical narratives of days old. I’m tired of seeing all that we can but feeling like I’m looking at the forest from my island while so many hide behind their own tree. I see the rehab space as one of, if not the most important, areas for making a positive impact and providing the greatest net benefit to those in pain. I see our role as so much bigger than the way we are currently functioning. I see our role in public health, lifestyle medicine, health coaching, rehab guidance, injury/pain consulting and education, and healthcare utilization reduction.
If we can break away from the 2-3x/week for 6 week hamster wheel of care for that 60-70% of patients who will mostly improve on their own, we can focus so much more time, energy, and resources on community education and engagement. We can free up time and space for that 30-40% who REALLY REALLY need us. We can explore sleep, nutrition, stress, fears, movement, behavior change, long term commitment and accountability, and so much more.
Yes, I know this is pie in the sky. Yes, I know this doesn’t work with the current insurance model. Yes, I know that referral sources and institutions don’t see it this way for the most part right now. Yes, I know it will be a crazy uphill battle. But damn, wouldn’t it be nice? To practice at the peak of our degrees? To have a greater impact? To save fu**tons of money, and be rewarded with a nice slice of the pie for doing so? Maybe, just maybe, if we can get enough people looking through this lens we can create a voice loud enough to be heard. A voice loud enough to influence how the systems that confine us function. I know I’ll be singing this song at the top of my lungs from the highest peak of the tallest hill. I’d love it if you would consider joining me.