Posted on Wednesday April 18 2018 by Ollie Herridge
It is another day in a busy east London GP practice and I just treated my 10th of in total 14 patients. During my break, I checked my twitter timeline and was reading all the fancy posts about the latest - however often inconclusive - research findings in physiotherapy. While I was scrolling down, I heard this little voice in my head calling me a traitor, as I implemented soft tissue technics in my management plan for low back pain conditions.
When I finished my Masters, I remember that I had thrown away my manual therapy book (something I now regret by the way) and refused to do the old fashioned "hands-on" approach. I felt like a pioneer in the group of physios "who got it". Thus my management plan for i.e. low back pain consisted mainly of education and exercise prescription. But for some reason this evidence backed up approach worked for some but not all of my patients. I felt a bit helpless, so I decided to do what some patient "expected" from me to do and I got better results - or at least for me and the patient less frustrating results. So am I a traitor? Will I lose my degree because I do not comply with the latest evidence for i.e. chronic low back pain? Not sure if it is as simple as that.
In his book "intelligence in the flesh", Professor Guy Claxton describes the human being as "complex dynamic system". A complex system is a system made of various components, which can interact with each other and adapt in order to keep "homeostasis". What emerges from this complex dynamic system is the individual, with its beliefs and expectations conditioned by the cultural and social environment it grew up. Interestingly, expectation and conditioning is thought to play an important role in the placebo response to treatment. The physiotherapist is by many people still expected to work "hands-on" - or how many times did you hear the sentence, I quote: "the physiotherapist did not even touch me". So by respecting the patients expectations and experiences for, i.e. a hands-on treatment, there is a chance that I trigger a placebo response and build a therapeutic relationship. This therapeutic relationship could help to "get the patient on board" when I talk about the multifactorial dimension of pain and the benefits of active exercise in the management of, for example, chronic low back pain. But don’t get me wrong; I am absolutely aware that a hands-on approach only could feed into passive coping mechanism some patients demonstrate. So I use yellow flags as a guide to inform me how much "hands-on" could be ok for the patient.
After number 13, a lady I treated successfully with a combination of hands-on, education and exercise for her low back pain, is a gentleman who has suffered chronic low back pain for most of his life. Over the three times I saw him so far, I mainly listened to understand and clarify maladaptive health beliefs and demonstrated the latest findings in chronic low back pain research. He improved 95% and was discharged after four sessions. I did not touch him a single time. Well, back then during my masters, I did not really understand the meaning of Roger Kerry`s "n≠1", but I think I do now. Evidence based practice consists of the evidence together with the clinical experience of the practitioner and the patients experience.
Fabienne Theler is a physiotherapist, born and studied in Switzerland and obtained her Master in Advanced Neuromuskuloskeletal Physiotherapy at King`s College London. Currently based in London, she works as a neuromuskuloskeletal physiotherapist and regional manager. She loves travelling and the experience of being surrounded by individuals from all over the world. She is grateful to have learned extensively from amazing people including her patients, peers and lecturers.