To date I have tried not to make any blogs I write too difficult to read, and I have included key references only to help provide some background into my thoughts… This is no exception and I make no apologies about the pure, unadulterated anecdote and personal thoughts that make up this short blog!

Today I wanted to write about how my thoughts have developed when it comes to prioritising what I NEED to do when treating different patients. Because this can be a conflicting area.

If you are new to treating MSK patients or are starting to peek your head above the parapet regarding your treatment choices then the different dogma’s around treatments, complex presentations and lack of clear treatment algorithms can leave you picking up the different bits of your brain off the floor after a long clinic… why did I choose to give that treatment again?

When it comes to exercise provision, the research is murky to say the least, off the top of my head I can say:

• ROM, Strength and endurance have no significant role to play in managing low back pain

• Quadriceps strength accounts for 2% of improvements in exercise based interventions for knee OA

• Hip and quadriceps strength has no impact on hip arthritis pain

• Lower limb strengthening, of both high and low intensity don’t outperform attention control in knee osteoarthritis

• Structured hip or knee exercise doesn’t outperform free activity in people with patellofemoral pain

• Outcomes for corrective exercise for scapula dyskinesia aren’t different from general exercises

• Strengthening hip flexors and adductors works just as well as hip abductors / external rotators / extenders in people with patellofemoral pain

• There is no clear winner in exercise for management of low back pain

• There is no difference in types of loading for Achilles tendon pain

• Throwing the kitchen sink at people in terms of physio management doesn’t outperform turned off ultrasound and self applied ultra-sound gel for hip OA or knee OA

If I was to dive into the depths of my dropbox you can bet there would be many, many more papers along the same lines [The pain of searching my dropbox was too much, DM me for links if you want to read more about any of these points!]

On the surface of things you could say… so strength / endurance / range of motion / specific loading metrics don’t matter then? And you would be right (for a large majority of patients).

… For certain populations. Namely, people who present with atraumatic, painful conditions. It seems that the mediators (causes) of recovery to get out of pain are still largely unknown to us and the traditional way in which we have delivered treatment may be more the vessel for the actually important stuff.

This important stuff is probably things like;

• Validation

• Comfort provided from active listening / allowing patient to tell their story

• Reassurance

• A feeling of optimism that their body isn’t actually as broken as they thought it was; starting the path from bodily doubt towards bodily certainty / confidence.

• Permission to move again / reductions in fear or apprehension of movement

• Through validating a patients problems, opening up new doors in their social circumstances e.g. change in work situation or their partner finally giving some sympathy instead of telling them to stop moaning!

The above isn’t an exhaustive list, but there is a common theme amongst them all in that, if you try and measure them you are probably going to measure them wrong. Patient reported outcomes measures will inevitably have some drawbacks to their use as what is e.g. fearful movement to one person won’t be the same for another (this doesn’t mean PROM’s aren’t useful, they are the best we have for psychometric data, but we need to be critical of the limitations); what validation means to one person is very complex and very different to what validation means to another person.

In other words, they are intanglible. We can’t touch / perceive these things directly. Now that DOES NOT mean they are unimportant. As we have deduced from the above studies, the tangible stuff that we can measure doesn’t seem to matter that much on average when it comes to recovery. So, the odds that the intangible stuff actually IS important just shot up.

Sorted!

Oh wait, yeah, no there are tonnes of other types of patients that we also treat!

These are the patients that have undergone a trauma or surgery, some of whom will have significant physiological changes as a result. In my role as a lower limb physio, this will commonly be atrophy / loss of cross-sectional area of musculature, changes in tendon structure post trauma or change in physiological properties or stiff as f**k joints.

It’s a hard stretch to imagine that such gross changes in physiology will not have an impact on a person’s desired quality of life or symptoms if not addressed. When it comes to research about this then it gets a little tricky… I’m not aware of any trials that have really looked at this in terms of physiotherapy management post trauma / surgery.

We have to be a little careful here when talking about terms such as quality of life or function because humans are classically plastic. We adapt to new circumstances very well (usually). This is probably a contributing factor to why outcomes for surgery aren’t that different to non-operative management for traumas such as proximal humerus fractures or distal radius fractures. These are fragility fractures and the people who have them probably accept they won’t be back to ‘normal’ and adapt quite nicely to it. If they can’t do something one way then they just do it another. No biggie. Ask them about quality of life? ‘Yeah it’s great’ or at least no worse off because of the inconvenience of restricted function.

But if the constraints the injury imposes are significant enough to reduce movement variability, then it can be a big issue. Classic examples of this would be older patients following quadriceps or achilles tendon rupture that don’t get enough force back to descend the stairs properly or with any confidence; or a younger patient post tibial plateau fracture ORIF that has been non-weight bearing for 6 weeks and then partial weight bearing for the next 6 weeks who then can’t generate enough force to decelerate and change direction enough to be competitive in their sport.

In these situations, you bet the tangible stuff matters. It matters a hell of a lot! And we should be tracking it and planning our rehab around it. The sweet thing about this is, if you go back to look at the list of ‘intanglibles’ then it’s obvious we can tick all those boxes as well by giving out our specific, tanglible variable targeted interventions.

Now onto the purely anecdotal stuff. When I am confronted with a patient and I am thinking about giving out an exercise I ask myself one key question…

Is it pain or function that I’m targeting?

If it is function, then I need to measure and track my tanglible variables such as ROM, strength, endurance e.t.c. So long as I am a good communicator / decent human being and actually care about my patient I should hit all the intangible variables too.

If it is pain, then I don’t really NEED to care too much about tangible variables. On average they probably don’t matter anywhere near as much as most of us think they do. At least not when first giving out exercises (if someone doesn’t then improve it might be worth looking a bit deeper into it).

The important bit when treating people primarily for pain is that we don’t end up missing, or even worse, actively go against the intangible variables. Just because I don’t need to be super specific with my exercise choices doesn’t mean I don’t need to validate and give a reason / narrative to my patient. If anything, I probably need to put in a little extra time to make sure they realise I do believe they are in pain, that it is as shit as they say it is and that actually we can help them along with some form of activity or movement. It just so happens we have a HUGE amount of options in front of us that we need to work through to find out what is best (i.e. enjoyment, practicalities, relating to core values e.t.c.).

‘Pain or function’ I ask myself when confronted with a patient with knee osteoarthritis that is struggling to get up the stairs due to pain related de-conditioning… If we can both agree that to get up the stairs easier is one of the main goals then it makes sense to track quads strength as the ability to produce greater force through his quads will probably make the whole thing a lot smoother! If actually he doesn’t care about how he does the stairs, so long as he does them, but it’s the general pain day to day that’s the matter then quads strength suddenly becomes less important!

This is a level of reasoning I’m comfortable with. It’s not perfect and there is of course nuance to it, but on the whole I don’t think there are massive holes in it – if you can point any out then I would like to hear about it so I don’t become TOO comfortable.

To anyone out there struggling with this type of reasoning, give this framework a go and see how you go, I hope it helps! Yes it might well be a false dichotomy in terms of representing a patients experiene as people don't have either pain or function problems, it's usually both, but that doesn't mean it can't be helpful for us. I have tried to summarise a lot of my thoughts into this way to simple graphic below!

As always, thanks for reading and reach out with any queries.

Jeff