Trustworthy Trent or Rip off Rick

Neil - Doctor of PhysiotherapyBlog, Events, Health, Uncategorized0 Comments

As a Physiotherapist with a special interest in pain, I reckon I go alright; much better than I used to anyway, when my bar was so low I could only barely get under it.

As a mechanic though, understanding the myriad of funny noises that my shit-box of a car makes sufficient to have any inkling of how to respond to them, I say with absolute confidence that I know the square root of bugger-all. My tendency to date has been to ignore those noises in the hope that they will eventually go away and I can happily go on pretending that I never heard them. The engine cover for instance has been sitting in my boot for more than two years since an RACQ man removed it on a call-out and I haven’t been bothered to screw it back on again. I guess the noisy ‘woodpecker’ under the bonnet must have died.

I simply could not invest any less physical or mental energy on my car and I’m very happy to pay a mechanic to take on that burden for me. I just drive it. Being completely ignorant to the issues did once cost me a $5000 engine re-build in 2009, so I am somewhat wise to what can go wrong.

My wife’s car is Nissan Dualis. We bought it new 5 years ago and it’s in good nick. She’s a GP and much smarter than me but arguably as mechanically inept. The image in this post is the latest service invoice from Gold Coast Service Centre. The total was almost $1000. I’ll add that the scheduled service was more than six months overdue!

I met the owner Trent at a local Business Networking event last year. The car needed to be serviced at the time and he seemed like a decent bloke so I sent it his way. Ever since then he’s been taking care of both of our cars and he now trains with us at PRIDE. I recommend him to everyone who owns a car, even though I know nothing about what he actually does. Why do I recommend him? Because he’s a nice bloke and I trust him.

Having looked at the car he called me to let me know what they’d found. As a scheduled service and way over due, I was expecting there to be several things which would need to be changed or replaced. Trent outlined what they’d found and told me that if cost was an issue for us we could hold off doing X, Y and Z, but the brakes and rotors “have to be replaced”. Not that the kids’ seats in the back make safety a higher priority, but his responsibility as a mechanic to ensure that our car is safe and roadworthy was clearly his priority. He’s a very down to earth Aussie bloke with a big manly beard and if face-to-face at his workshop he would usually just tell me straight; “mate, they’re fucked”. Being English born and raised, I find that approach disarmingly honest. And funny.

I had no reason not believe him and it was only an extra $200-odd for the things that could have been put off until later. Being a believer in the principle behind Aesop’s fable of the goose with the golden eggs, I opted to have everything done without hesitation because I understand that if I run it in to the ground, I risk losing the car altogether. At least I learnt from my mistake after the rebuild!

The point of all this is that Trent is a service provider. He has knowledge and skills that I don’t. If I don’t service my car, sooner or later something avoidable and unwanted will happen. As a Physiotherapist, I have knowledge and skills which can help people. If we don’t take care of our body and health, avoidable and unwanted symptoms will occur sooner or later. We simply cannot ignore our health. We cannot ignore the unwanted symptoms of disease and disability else there will be consequences.

I may ignore my car and have zero interest in looking after it, but what’s the worst that could happen? something breaks and I’m forced to replace it; the whole car is replaceable if need be. I cannot have the same irresponsible attitude to my health though. I don’t need to spell out the worst-case scenarios there – any hospital or care facility will attest to that.

There will also be some people who seem to be able to run their cars into the ground without repercussion. Some people buy new cars and they break. The same can be said for people and their bodies. They’re the outliers.

The human body and health is frequently compared to a car or its engine but it’s so much more complex than that! Things can and will go wrong. People get sick and accidents do happen.

How you feel, how you move, how you perform, how you look – they’re all potential indicators of something which could or should be different.

Our Director Jenny’s father is a retired RACQ service man. He services all of the family cars, unless it’s a more complex issue like an automatic transmission, in which case he has someone else more skilled take care of it. As individuals, we’re 100% responsible for our own body as we don’t have the luxury of being able to hand it over for a service. I have heard of that sort of marketing, and ashamedly my own business cards in 2006 used to promote a similar message; that’s just utter nonsense. Everyone *should* have sufficient knowledge and skills in regard to their own body to be able to take care of it to maintain a minimum level of health; whatever the markers for that may be e.g. blood pressure, body fat, being able to walk up a flight of stairs without struggling.

If our health fails, when accidents happen, we may well need some input from a healthcare provider, like a Physiotherapist. That’s what we’re here for! That doesn’t mean however that the therapist assumes responsibility for someone else’s health. Far from it. Time spent with a healthcare provider is likely to be less than 0.5% of the 168hrs in a week. Even the “unlimited” Physiotherapy programs in reality are still very small and insignificant. What you do with your body in the other 99.5% of your time is entirely your responsibility, and it’s how you chose to spend *that* time which is most important. One salad or one training session in the gym doesn’t address obesity. One day abstaining from drink doesn’t address alcoholism. What you *take away* from the 0.5% is important though.
Our role is to empower you with the knowledge, skills, and hopefully a little motivation if it’s lacking. Our role is not to fix people, it is invariably to change or motivate behaviour to achieve a desired outcome.

The other slightly more sinister side to this picture is the scare mongering, over-diagnosis, over-servicing, over-use of investigations (imaging) discussed in the Wise Choices paper by Traeger et al earlier this year.

Have you ever heard of a mechanic taking advantage of a vulnerable customer and doing the wrong thing, like replacing parts that don’t need to be replaced? I have. There are plenty of examples: here and here.

I am the perfect target for a shonky mechanic. For the purpose of illustration, I’m going to briefly ham-it-up…

I was a student when my engine shit itself. It costs me (my parents) $5000. It died on a very busy road at a set of traffic lights right in front of the garage I was taking it to. It was a memorable experience that stuck with me for all the wrong reasons, not least because I was forced to push it up a hill. Now every time I hear a noise under the bonnet or feel a sense power loss from the accelerator, I start to panic thinking that it’s the same thing happening again and the car’s about to die. It’s stressful, makes me anxious and I’m fearful of what might happen (I did say that I was going to ham-it-up!).

The same happens with health. If someone’s been unfortunate to have a brain tumour, it’s likely that every subsequent headache becomes a ‘potential’ brain tumour. Fear is generally considered a reaction to something immediate that threatens your security or safety (ref), it is a powerful driver of behaviour! It is entirely possible that a shonky mechanic who knows my history could induce sufficient fear of another potential engine failure and have me spend thousands of dollars on parts that make no difference to an otherwise normal engine. Similarly, it is entirely possible that a shonky healthcare provider could induce sufficient fear in someone that they spend thousands of dollars on unnecessary treatments that have no effect – that’s what the Wise Choices paper is all about!

I took Trent’s word for it that the brake discs and pads needed to be replaced. If he told me that X, Y or Z needed to be replaced because the car wasn’t safe to drive, I would pay for it. If he threw in a story of someone else who had the same problem who had run off their road with kids in the back, I’d be scared shitless and definitely pay for it.

Where there’s money to be made, there are people lined up to profit from it. Healthcare is no different and you would be naive if you thought otherwise.

How you do you know if your Physiotherapist is a ‘trustworthy Trent’ or a ‘rip-you-off Rick’? You probably won’t.

Dr John Quintner is a retired physician in Rheumatology and Pain Medicine. If you were to ask him, dry needling as a recommended treatment would be an automatic black flag, as would be any form of intervention supposedly targeting ‘trigger points’. Depending on who you ask, applying various forms of sticky tape to people or use of different machines (ultrasound, radial pressure wave, TENS) may also raise further red flags of suspicion that you’re perhaps paying the provider for something that has no evidence of specific effect.

In this wonderful interview with Professor Peter O’Sullivan on the Pelvic Health podcast with Antony Lo and Lori Forner, Peter is very clear in separating the pain associated with trauma and true pathology in someone presenting to a Physiotherapist, from other forms of pain.

“What it reflects is our underlying implicit fear of pain, that we fundamentally as human beings are encultured with a view that pain equals damage, that something’s wrong with your structure, that you’ll find it on a scan, and if you don’t’ find it on a scan, then we use these little tests that find asymmetries and dysfunctions that tell you that there’s something fundamentally wrong and vulnerable in your body and that leads down this path of avoidance, fear, hyper-pain, hyper-vigilance, which we reinforce all the time in practice by telling people these bits are not in place and these muscles aren’t quite firing right and fundamentally it strips people of their self-efficacy

The things that we have thought are important like structure, dysfunction, imbalances, posture, all the stuff that we’ve been told, that we teach people are important, are very poor predictors of people’s pain. The things that look like are really important is the perception of threat [ ] and that’s influenced by your cultural background, your fundamental beliefs, your social situation, your lifestyle factors, how much sleep you’re getting, your levels of anxiety, worry, mood, interactions with your environment, physical loading, all of those factors set up a risk profile that may mean you do get pain or you don’t. How you respond to that pain really comes back to that understanding you have of ‘what does pain mean’.

The worst thing you can do for someone who’s lacking self-efficacy, who’s frightened, is become the therapists who takes their pain away.

This is the other thing I think we’ve encultured is this idea that we have to be pain free society. I feel pain in my body every day, does it bother me, no, do I pay attention to it, no, does it stop me doing the things I love in life, no, is it a problem for me, no. This idea that any little pain shouldn’t be there, we’ve kind of created this belief that pain is abnormal. Pain is just part of life, pain is normal. Where it’s not helpful is when it is threatening, when it disrupts your ability to do the things you love, when it takes away your confidence to do those things, that’s when it’s a problem

“We need cultural shift basically because you’ve got an industry that is feeding into the misery of human beings out there and it’s not getting better.”

In the absence of trauma or something being fundamentally wrong with the area of pain, it may well be that the challenge is with pain itself and nothing to do with any underlying tissues. “What is pain?” would be a wonderful question to ask the person proposing to treat that ‘experience’….if only the lay person was in a position to make an objective interpretation of the response!

Pressure is a ‘sensation’; hot and cold temperatures are a sensation and we have specialised receptors in the skin to detect those. Love and pain are ‘experiences’; both are very real and they can create equally very real physiological responses, but we do not possess receptors in our body for love or pain because they are feelings and experiences, not sensations. The distinction may seem pedantic however, pain as an experience has and continues to be poorly understood across the profession. As Peter’s comments indicate, Physiotherapists have for a long time been incorrectly attributing pain to many things, all entirely unhelpful for the person with pain. It is also an important distinction because non-trauma pain is the most common reason for someone seeking help from a Physiotherapist.

I posed this question on Facebook: “Do Physiotherapists who routinely recommend care plans to people (in whatever form) actually spend the same amount of money on a therapist when they have the same symptoms…….or do they chose self-management??”

If the answer is “no”, why not?

If treatment for a condition is *necessary* surely everyone would require the same? If the Physiotherapist can self-manage, why would they not be teaching other people to do the same? It’s not rocket science.

Do as I say (and I’ll charge you for it), not as I do.

I’ve spent more time with pain during the past 18+ months since opening PRIDE Physiotherapy than any other point in my 42 years that I recall. At one point, I had started to catastrophise because I was unable to lie on my back and thought I may have fractured a rib. I hadn’t. I wrote a lot about my own pain experiences last year but not once did I receive treatment for anything. That’s not reflective of being stoic or stupid, just knowing that there was no trauma or true pathology and that the pain in every instance was normal and would disappear regardless of what treatment I may have received. Many things provide a temporary and transient relief of symptoms, but that is not a specific effect, nor should it justify a treatment intervention unless specifically for that purpose, and if the person being appropriately informed about the experience of pain and altering a time course. I had a really painful neck a few months ago and would gladly have paid someone to make me feel more comfortable, even though I  knew  full well that it was going to resolve. More often than not, our role is to reassure people that it’s ok, it’s going to go away on its own, and help them along the journey of self-management. Physiotherapist and Osteopath Stephen King was spot-on with his response.

When we get a common cold, it has a natural time course and will get better all on its own. That’s called natural history. Of course, there are plenty of things we can take to manage the unwanted symptoms of a runny nose, sore through and feeling like crap, but those symptom modifiers are just that; they do not alter the natural time course of the infection. The human body is remarkably adept at taking care of itself.

If you’re seeking assistance from a Physiotherapist for something other than rehab after trauma or management of a true pathology, it would be wise to reflect upon Prof O’Sullivan’s comments and ask yourself a few questions to determine if you’ve got a Trent or a Rick:

• Have I been told that I am damaged when where was no obvious trauma or overload?
• Is my pain being blamed on something being wrong with your structure?
• Is the cause of your symptoms attributed to something found on a scan?
• Have you been told you have problematic asymmetries and dysfunctions?
• Are you feeling vulnerable?
• Have you been told that your muscles aren’t switching on, firing properly, or weak?
• Have you been told something’s wonky, out of place or misaligned?
• Do you have an imbalance or poor posture?

‘Rick’ peddles these reasons for treatment.

 

“The worst thing you can do for someone who’s lacking self-efficacy, who’s frightened, is become the therapists who takes their pain away.”

— Professor Peter O’Sullivan

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