I will make the assumption that we all believe we provide our patients with good treatment, but what does this look like? In physiotherapy we have so many “camps” or methodologies which advocate that their method is best, and yet people get better in many different ways and with many different methods of treatment. This obviously flies in the face of the idea that treatment has to be specific, however we should ask what are the common elements that people succeed with?
I would argue that there are three things which make for good, effective treatment, and if you are missing anyone of these you could be providing better care:
2. Hands on care
Education – Instilling hope!
As physiotherapists, we are privileged to have people entrust us with their bodies, and look to us for guidance. As such we need to be able to provide them with education on their pain, symptoms, injury or whatever brought them in to see us. I have already beat the drum of pain science as the best form of education to improve outcomes (see that blog here). Beyond that, education should give our patients an idea of what they can do, what they may want to minimize in the short term, and how they can help themselves move forward. Beyond these basic requirements, I contend that education should encourage and empower our clients with the knowledge that their efforts will get them better – as a physiotherapist we should see ourselves as the guide in this process and not the one who will “fix” them.
There is evidence that poor education does not enhance outcomes and recovery (in these cases patho-anatomical descriptions of pathology was the focused– ref, ref). Compare that to positive / encouraging education and we see improvements in patient satisfaction, patient outcomes and overall recovery (ref, ref). This body of literature supports the notion that positive educational messaging has a meaningful influence on functional and clinical improvements.
Additionally, several recent perspective papers advocate for the use of manual therapy and pain neuroscience education to show patients that their symptoms are modifiable to instill hope (ref, ref, ref). This is perhaps one of the chief mechanisms of our treatment – to instill hope.
Hands on care – The experiment!
If education is delivered to instill hope, then manual therapy may be the experiment that shows this hope can be a reality. As MSK practitioners, this is the arena that we spend much of our training trying to perfect. However, we should likely be paying more attention to the things that surround the “theater” of manual therapy, the things that help MT have an effect (patient expectations - ref, ref, ref; clinician beliefs - ref; therapeutic alliance - ref). Possibly most important of all in hands on care is the use of a test re-test approach to show patients that their symptoms are modifiable. In my view this the largest value of manual therapy as the effects of manual therapy are only temporary (between 5 minutes and 24 hours; ref), but the realization by the patient that their symptoms can change lasts much longer. It is the role of the therapist to seize this moment of realization and further re-enforce the idea with more education and positive re-enforcement. This is the iterative process of good treatment – educate, make a change, educate again, and always encourage.
Now, I know that there are “camps” out there that bock at the idea of manual therapy, as the research shows it to have a small effect; so let me paint hands on care with a broader brush stroke to include the physical assessment. Here we have an equal opportunity to enforce the idea that symptoms are modifiable. Anecdotally, I have worked with patients with acute WAD that have decreased their pain significantly and increased their cervical range after simply demonstrating that their passive motion is full and pain free (obviously this doesn’t work for everyone – but wouldn’t it be nice if it did). Again, I use this as an opportunity to educate them that the structures of the neck can still move pain free to instill hope.
Exercise – The proving ground!
After education to instill hope, and hands on care to suggest that it can be a reality, exercise is the proving ground! Here patients get to prove to themselves that they can positively impact their symptoms. The premise is that by experimenting with their limits, patients gain a measure of confidence and self-efficacy. Cory Blickenstaff describes these as clinical experiments that help patients explore the limits of their symptoms – what he calls “edge work” (listen here). These experiments are a physical confrontation with fear avoidance, which is a well established risk factor for poorer outcomes. (ref, ref).
As useful as it is, the idea of symptom exploration is secondary to the value that exercise has to improve function, relieve pain (ref, ref), adapt body systems, and improve health (ref). In these ways exercise builds physical capacity, skilled movement, and tissue resilience (the “bio-”) while also re-enforcing the positive message that they can improve themselves and their symptoms ( the “-psycho-“), leading to improved quality of life and community involvement (the “-social”).
Again, use of the test re-test approach can illustrate that change can be made, and now not just by the therpist, but by the patient with exercise. I would argue that there is no greater gift in MSK medicine that you can give to your patient than the sense that they can treat themselves! Exercise does this. It proves that they can feel better, move better, and return to the things they love.
It’s an iterative process.
It is important to understand that these three elements of good treatment are best used as an iterative process in their delivery, where one plays off the others to encourage a continuous therapeutic exploration of the patient’s limits (which are often further than they expect). This exploration of limits is the process of improving one’s self. It is important to realize that with few exceptions (red flags) these limits are rarely dangerous to explore. Obviously there are those patients that we have to pull back, but the majority need encouragement and guidance through our treatment, they don’t need to be “fixed!”
So what is good treatment? An encouraging mix of education, hands on care, and exercise designed to allow our patients to develop independence and self-efficacy in their own ability to recover from injury and pain. Obviously, these elements will be mixed together in differing doses for each patient, as well as through the course of care, but without each aspect involved your good care could be better. And our patients deserve not just good, they deserve the best!