In reply to “Your Back and your backyard” by Greg Bell
To paraphrase Tim Minchin, alternative medicine is just medicine that’s either not yet been proven to work, or been proven not to work.
The thing he didn’t say is that all professions have a choice where on the alternative-versus-scientific continuum they position themselves. Do they push on into the uncertain world of evidence-based practice? Or do they stick to their comforting traditions? Astronomy chose the former, astrology chose the latter.
Every now and then I get the feeling that New Zealand’s physiotherapists are drifting towards homeopathy on that scale.
My most recent “Oh no, we’re becoming palm readers” moment sadly came courtesy of the Physiotherapy New Zealand website. In August this year Greg Bell and Physiotherapy New Zealand published an educational article, “Your back and your backyard” aimed at the droves of people heading into their backyards as the sun returns to Aotearoa.
In the story, Bell painted a dramatic picture of gardeners’ discs wearing out like Formula One car tyres and falling apart like over-laden hamburgers. He said that, “In the laboratory, discs have been put through their paces, so we now know that all discs have a finite number of bending cycles before they fail,” and that the answer, he tells us, is to learn how to lift properly.
At a glance it seems like pretty innocuous stuff. But I’d argue that this well intentioned article is based more in comfortable tradition than up-to-date research. As a consequence he’s not doing readers any favours – and in many cases it may be doing significant harm.
It’s time to drop lifting training
The article’s central message; that the drug-free, surgery-free approach of manual handling training is a potent weapon in the fight against lower back pain is certainly comforting to us physiotherapists. But as Richard Dawkins once said, “The fact ‘X is comforting’ does not imply ‘X is true’.”
A 2007 BMJ Group systemic review of training and lifting equipment pooh-poohed the idea. Likewise a 2009 Occupational Medicine Journal literature review concluded that, “Manual handling training is largely ineffective in reducing back pain and back injury.” And in 2011 the a Cochrane Back Group study concluded, “Manual material handling advice and training with or without assistive devices does not prevent back pain or back pain-related disability when compared to no intervention or alternative interventions.”
Sticks and stones may break my bones, but words will never hurt me?
The somewhat outdated conclusion isn’t great, but it’s not the major problem with the article. To see that, we need to look at the colourful analogies used to explain the supposed need for lifting training: exploding hamburgers, discs cycling inevitably towards their used-by-date and of course worn out Formula One tyres. These analogies are completely at odds with the Fear Avoidance Model (FAM) model of chronic pain.
In case you’re not familiar with it, here’s a good explanation by Dr Neil O’Connell: “In the acute stage of an injury or painful event, the presence of fear and catastrophic beliefs regarding the meaning of pain or the possible consequences of activity leads to hyper-vigilance to symptoms, avoidance of activity and subsequent disuse, depression and disability which self-perpetuates in a vicious cycle.”
It’s early days for the model yet, but evidence like this 2013 meta-analysis by the Journal of Pain is already building to suggest that implanting catastrophic beliefs that discs are ticking time-bombs or exploding hamburgers is potentially setting people up for a lifetime of hyper-vigilance and chronic pain.
I want the truth dammit! (…You can’t handle the truth!)
Of course there is an ethical argument to be made that the patient has a right to know; that if they do have a disc like a worn-out Pirelli, we owe it to them to look them squarely in the eye and say, “Your back’s munted mate.”
But the problem is in many cases we don’t actually know if it is the truth. Sources like this 2007 Journal of Orthopaedic and Sports Physical Therapy clinical commentary, which say, “Identifying relevant pathology in patients with LBP has proved elusive and is identified in less than 10% of cases,” should be enough to make good physiotherapists think twice before dropping a gruesome metaphor into conversation with a client – let alone publishing them to the community as a whole.
But it’s all harmless enough… right?
The response from physiotherapy’s administrators on this sort of low quality information is that it’s aimed at the healthy general public, so “it doesn’t do any harm.” This raises two concerns.
Firstly, surely as a profession we should be setting our sights a little higher than that. Keep in mind clients can have no harm done by visiting a homeopath, or a crystal therapist… or by spending their money on a nice dinner out with the family.
Secondly, with one in eight New Zealanders living with chronic pain, the odds of reinforcing catastrophic beliefs in exactly the wrong people are too high to ignore. Sadly in this day and age, addressing the general public means addressing chronic pain sufferers and their peers.
The upshot: Grow a backbone people.
Isaac Asimov famously said, “Inspect every piece of pseudoscience and you will find a security blanket, a thumb to suck, a skirt to hold.”
It seems like that’s the case here. Too many physiotherapists in New Zealand are clinging to out-dated ideas – one of the hallmarks of pseudoscience – because it’s an easy, comfortable, commercially rewarding strategy. That’s bad enough on its own, but in cases like this one, Physiotherapy New Zealand has endorses those ideas by republishing them.
If we want to meet our professional goals and be taken seriously as a profession, then we need to have the fortitude to drop the security blanket, to look past our intellectual comfort zones to what’s best for our clients.
PS – as you’ve probably gathered by now, I’m a big believer in a constructive debate. If you think I’ve got it wrong, gather some evidence and let me know!