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A letter to a prospective patient

Updated: Jan 11

By Dave Emond


So you’ve hurt your (insert body part), and you are hoping to get some guidance. "Who do I go see? What do I get done? How long could this take?" You want to know what to expect in a world with so many options. The intent of this piece is to help guide you in your journey to get the best care possible, be able to recognize practitioner red flags or misinformation, and to understand what to realistically expect from a musculoskeletal healthcare practitioner.


From who should you should seek care?


There is significant overlap in many of the manual therapy professions (physiotherapists, chiropractors, osteopaths, etc.), despite their claims to offer different options, often leading to confusion or altered expectations (1,2). So let’s simplify this. The truth is, none of these professions holds the single answer, as there is yet to be any specific therapy that has solved our rapidly rising cases of musculoskeletal pain (dealing with muscles, joints and associated tissues) (1). The best we have to date for effective management is education on self-management strategies and exercise (3).


If you visit a practitioner who follows the best practice guidelines, they will all offer the same general care independent of their title. You will get: education, reassurance, exercise, and if appropriate, small amounts of passive therapy as an adjunct to help out along the way (3). Given the fact they will be offering similar services, you can make your experience more enjoyable and effective by working with someone you like, and who is willing to listen to your story, regardless of their profession (4-6).


There seems to be a lingering battle of superiority between members of various healthcare professions, which really comes down to ego and wanting to be special. I sincerely empathize if this has played a negative role in your healthcare management and experience. We should all be on the same team and our individual professions should not come first. You and your health comes first.


What should your first appointment look like?


When you go see your practitioner for a new complaint or injury, the first priority is for us to understand your whole story. This can sometimes take a while, but it really gives us a better idea of how we can guide you. We want to help you to the best of our abilities and to the best of yours. This may take 15 minutes or it may take 90. It all depends on your story. Some questions may seem “out there”, but the key to this conversation is to understand your circumstances as a whole person; not as a low back, or a knee, or a shoulder. The assessment can also be part of the therapy by putting your mind at ease (7), because “Dr. Google” is frequently wrong.


This may be time consuming, and you may be thinking “I don’t care about the details, just FIX me”. Unfortunately, this is one thing we can’t do as musculoskeletal healthcare practitioners. There is no fixing. There is only helping.


What is the role of passive therapy?


So I mentioned earlier that guidelines suggest the use of “passive therapy” as an adjunct to education, reassurance and exercise. What is passive therapy, and what does it do?


Passive therapy means you as the patient are not participating in the therapy - you’re having something done to you. This can include massage or soft tissue therapy, joint manipulation, acupuncture, instrument assisted soft tissue therapy, laser therapy, ultrasound, cupping, K-tape, percussion guns, and countless other modalities or techniques.


How might some of these benefit you? You may get moderate improvements in pain and disability, but often similar to the effects of natural history (i.e. time) (8). That’s it. Not to downplay the possibility of immediate but temporary reduction in your pain (this can obviously be a good thing), but in general, we aren’t doing the other things you often hear. We aren’t directly repairing or healing tissues, we aren’t changing your structures or “aligning bones”, we aren’t giving you sustainable strength improvements, and we aren’t “fixing” your biomechanics in the long term when using passive therapies (movement and exercise is a different story) (9). These are all unsubstantiated claims.


Passive therapy has a potential role to play as it may make your current pain more manageable in the short term so you can get back to being active and functioning at reasonable levels. Try not to mistake it for a magic bullet.


Will passive treatment prevent future injury?


No. We cannot claim or promise to prevent future episodes of pain or injury (10). An important risk factor for developing pain is a history of having said pain (11). If you’ve had something once, it may happen again. This is actually quite normal, and this doesn’t mean you are doomed. What may help is being well educated on the reasons for your pain, understanding that it doesn’t necessarily signify tissue damage or injury, and obtaining self-management strategies, increasing fitness and physical activity levels, which can all be used to manage potential future episodes (12).


Which passive therapy is best?


What may differ between practitioners are the options available for passive therapies. Some may not offer joint manipulations, some may not be certified to provide acupuncture and others may not offer that one gadget you thought might help. There are two things for you to consider here:


  1. Decades of research on these specific treatments continues to show that no passive therapy is significantly superior to another (8). For example, getting manipulated has similar outcomes as getting instrument assisted soft tissue therapy for low back pain (13).

  2. This is where your preference comes in. If you like the feeling of getting your muscles worked on - find someone who enjoys providing soft tissue therapy. If you prefer spinal manipulation, find someone who can offer that. Remember - these are NOT FIXING YOU, they are just your preferred method to temporarily manage your pain. Your expectations and preference play a large role in what you will get out of it. Positive expectations tend to lead to positive outcomes, and negative expectations often result in negative outcomes (14).


With this being said, if your practitioner is forcing a passive therapy that you don’t enjoy or feel comfortable with - tell them! Don’t pay money for a bad experience, and don’t be silent in this process. You are just as much a part of this process as we (the practitioner) are. In fact, you are the expert in your pain and day to day experiences; you know what feels good and what doesn’t.


Passive therapy is a small piece of the puzzle in your journey to getting better, so you shouldn’t have to worry about negative outcomes associated with your treatment such as “temporary worsening of symptoms”. If you feel much worse afterwards, it’s probably a good idea to switch things up; there are other options. If you stay silent, it is very tough for us to know what to change and how to change it. Trust me when I say this: a compassionate clinician appreciates getting feedback - good or bad. It helps us modify your plan to ensure you are getting the best experience possible.


How often should you be seen?


This seems to be pretty conflicting when we look at recommendations. Ideally, less is more (15), but this will depend on your situation. When is "more treatment" acceptable?


  • You benefit from the interaction as a whole (it’s nice to catch up, learn new things, with the potential bonus that it "feels nice" to get a little passive therapy).

  • You understand that the increased frequency of visits isn’t “fixing” you or “speeding things up” by any significant margin (8).

  • The extra frequency of treatment is not aggravating your complaint.

  • You have the monetary means to support these visits.

If this is you, by all means, enjoy within moderation!


You may have heard the term “maintenance care”. This is a controversial topic, as it is often taken to the far left field in the stadium of context. Here’s a brief synopsis of what we know about maintenance care for low back pain (10,16):

  • Maintenance care is not beneficial for everyone.

  • There is a specific subgroup of people with low back pain who may benefit from maintenance care. In the leading study of its kind, 38% of people who were considered “responders” to treatment had positive outcomes with maintenance care (a responder was someone who previously showed great improvements after 4 or less treatments prior to beginning maintenance care).

  • Maintenance care, in this specific population, can help reduce days in pain (on average 30 days less of pain per year), but DOES NOT prevent recurrence of future episodes.

  • People who can adapt and handle pain quite well (37%), should likely stay away from maintenance care as it can actually increase days spent with pain throughout the year (on average 10 more days in pain). If you fall into this category, it is best only to seek additional care if you cannot self-manage your symptoms.

  • Effective maintenance care is defined as pre-scheduled appointments by the clinician, and occur usually once every 1-3 months (not 1-3 visits per week, as some practitioners may suggest).

  • Maintenance care should not be limited to passive care and should prioritize education, reassurance and therapeutic exercise - otherwise it isn’t effective.


If you’ve been told to see a practitioner with high frequency over long periods of time, you’ve been “had”. If this is a personal choice (uninfluenced by your practitioner), you understand the risks, you have no expectations of prevention or important health outcomes (i.e. you aren't in pain and hoping to get better), or you are looking for the “pop” or “elbow in my muscle” purely for the fact that it feels good, that is your prerogative. I don’t need to eat cake, but it sure tastes good when I do. However, if I start consuming excessive amounts to the point where it becomes potentially detrimental to my health, I should probably ease off *wink, wink, nudge, nudge* (17, 18).


Conclusion


Do not confuse this as me trying to tell you that musculoskeletal healthcare professionals are not important. On the contrary. When working within the appropriate boundaries, we serve an important purpose in helping you along the way, as long as we put you first. This help comes in the form of educating you, empowering you by offering active solutions, and helping to manage your pain in the short term with a therapy that fits your mould as is necessary.


Our job as practitioners is to fit our plan of management to you, and not to fit you to our plan of management. Make sure your provider is best suited for you, ask questions, be part of the process, and if something seems a little fishy, maybe it’s time to go search for help elsewhere. The health and fitness industry can be both confusing and intimidating, so I hope this letter helps clear up a few things.



References:


  1. Haldeman S, Dagenais S. A supermarket approach to the evidence-informed management of chronic low back pain. The Spine Journal. 2008 Jan 1;8(1):1-7.

  2. Pincus T, Vogel S, Breen A, Foster N, Underwood M. Persistent back pain—why do physical therapy clinicians continue treatment? A mixed methods study of chiropractors, osteopaths and physiotherapists. European Journal of Pain. 2006 Jan;10(1):67-76.

  3. Lin I, Wiles L, Waller R, Goucke R, Nagree Y, Gibberd M, Straker L, Maher CG, O’Sullivan PP. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. British journal of sports medicine. 2020 Jan 1;54(2):79-86.

  4. Kaba R, Sooriakumaran P. The evolution of the doctor-patient relationship. International Journal of Surgery. 2007 Feb 1;5(1):57-65.

  5. Diener I, Kargela M, Louw A. Listening is therapy: Patient interviewing from a pain science perspective. Physiotherapy theory and practice. 2016 Jul 3;32(5):356-67.

  6. Lewis J, O’Sullivan P. Is it time to reframe how we care for people with non-traumatic musculoskeletal pain?. British Journal of Sports Medicine. 2018 Dec 1;52(24):1543.

  7. Adriaan Louw, Steve Goldrick, Andrew Bernstetter, Leonard H. Van Gelder, Aaron Parr, Kory Zimney & Terry Cox. Evaluation is treatment for low back pain, Journal of Manual & Manipulative Therapy. 2020.

  8. Artus M, van der Windt DA, Jordan KP, Hay EM. Low back pain symptoms show a similar pattern of improvement following a wide range of primary care treatments: a systematic review of randomized clinical trials. Rheumatology. 2010 Dec 1;49(12):2346-56.

  9. Bialosky JE, Beneciuk JM, Bishop MD, Coronado RA, Penza CW, Simon CB, George SZ. Unraveling the mechanisms of manual therapy: modeling an approach. Journal of orthopaedic & sports physical therapy. 2018 Jan;48(1):8-18.

  10. Eklund A, Hagberg J, Jensen I, Leboeuf-Yde C, Kongsted A, Lövgren P, Jonsson M, Petersen-Klingberg J, Calvert C, Axén I. The Nordic maintenance care program: maintenance care reduces the number of days with pain in acute episodes and increases the length of pain free periods for dysfunctional patients with recurrent and persistent low back pain-a secondary analysis of a pragmatic randomized controlled trial. Chiropractic & manual therapies. 2020 Dec;28:1-5.

  11. McLean SM, May S, Klaber-Moffett J, Sharp DM, Gardiner E. Risk factors for the onset of non-specific neck pain: a systematic review. Journal of Epidemiology & Community Health. 2010 Jul 1;64(7):565-72.

  12. Louw A, Zimney K, Puentedura EJ, Diener I. The efficacy of pain neuroscience education on musculoskeletal pain: a systematic review of the literature. Physiotherapy theory and practice. 2016 Jul 3;32(5):332-55.

  13. Crothers AL, French SD, Hebert JJ, Walker BF. Spinal manipulative therapy, Graston technique® and placebo for non-specific thoracic spine pain: a randomised controlled trial. Chiropractic & manual therapies. 2016 Dec 1;24(1):16.

  14. Bialosky JE, Bishop MD, Robinson ME, Barabas JA, George SZ. The influence of expectation on spinal manipulation induced hypoalgesia: an experimental study in normal subjects. BMC Musculoskeletal Disorders. 2008 Dec;9(1):19.

  15. Indahl A, Velund L, Reikeraas O. Good prognosis for low back pain when left untampered: a randomized clinical trial. SPINE-PHILADELPHIA-HARPER AND ROW PUBLISHERS THEN JB LIPPINCOTT COMPANY. 1995 Feb 15;20:473-.

  16. Jensen I, Leboeuf-Yde C, Kongsted A. The Nordic Maintenance Care Program: Does psychological profile modify the treatment effect of a preventive manual therapy intervention? A secondary analysis of a pragmatic randomized controlled trial. 2019.

  17. Waddell G. Low back disability: A syndrome of Western civilization. Neurosurgery Clinics of North America. 1991 Oct 1;2(4):719-38.

  18. Brownlee S, Chalkidou K, Doust J, Elshaug AG, Glasziou P, Heath I, Nagpal S, Saini V, Srivastava D, Chalmers K, Korenstein D. Evidence for overuse of medical services around the world. The Lancet. 2017 Jul 8;390(10090):156-68.