The Paradigms of Rehab & Medicine

Rehab and Med­ical Prac­ti­tion­ers across the world ded­i­cate their week­end, time and salary to the pur­suit of learn­ing new skills, knowl­edge and research so that they may help people. 

Why? Prob­a­bly because we all feel the need to improve our­selves, give a bet­ter ser­vice, con­tin­u­al­ly strive to be the best, or just because a gov­ern­ing body enforces CPD upon us.

In these con­fer­ences, cours­es and sem­i­nars, ded­i­cat­ed pro­fes­sion­als lis­ten avid­ly to the expert’ deliv­er­ing the con­tent. These Avatars of rehab can leave some of the audi­ence the feel­ing that their new found approach­es and tech­niques are the best thing since sliced bread and they encour­age an enthu­si­as­tic ven­ture with these new tech­niques to the detri­ment of pre­vi­ous­ly used meth­ods. I’m sure you are read­ing this arti­cle recount­ing the elec­trother­a­py you learnt at uni­ver­si­ty, the core sta­bil­i­ty’ that was hailed as the cure for all things includ­ing gin­givi­tis and lep­rosy and then there are the magi­cian manip­u­la­tors or acupuncturists.

These are sim­ply dif­fer­ent par­a­digms: A set of ideas or beliefs held with­in the mind.

And I won­der….. Are we actu­al­ly mak­ing peo­ple health­i­er than we used to?

Is the long term out­come of manip­u­la­tive ther­a­pies bet­ter than electrotherapy?

Are peo­ple get­ting fit­ter than they were? Are peo­ple recov­er­ing from injury any quicker?

Is the preva­lence of LBP any dif­fer­ent to the good old days of elec­trother­a­py or the sports physio’ with the mag­ic sponge?

There have been count­less research arti­cles that com­pare the var­i­ous approach­es to heal­ing with­in phys­io­ther­a­py and unless the research is car­ried out by a person/​persons who are pro­mot­ing their own approach, the results show very lit­tle dif­fer­ence between modalities/​beliefs (1,2,3,4,5,6).

Are we mak­ing peo­ple healthier?

Core sta­bil­i­ty had been researched exten­sive­ly in chron­ic low back pain and was found to be an effec­tive evi­dence-based prac­tice. Then, some of the very peo­ple who had been cham­pi­oning its suc­cess changed their par­a­digm and pro­duced oth­er research that dis­proved it. How much can we trust the evi­dence’, most of which wouldn’t even make it into a Cochrane review?

What can we do to stop our­selves being drawn into every new par­a­digm or fad’ like a hyp­no­tised flock of sheep?

There have been par­a­digms all through med­i­cine, and there will be more in the future. If you want evi­dence of this, you need only con­sid­er the his­to­ry of our great pro­fes­sion. Kuhn (7) pre­sent­ed his the­o­ry of sci­en­tif­ic rev­o­lu­tion, and Hewa (8) argues that the devel­op­ment of West­ern med­i­cine from Hip­pocrates to the present has involved a rev­o­lu­tion­ary change in par­a­digms, caus­ing pre-exist­ing beliefs to be thrown out with the bath­wa­ter to help bet­ter explain cur­rent health prob­lems. Hip­pocrates argued that walk­ing is man’s best med­i­cine’ and it seems he was right, although this era of med­i­cine also saw a belief that health was relat­ed to the 4 humors; an imbal­ance of the prin­ci­ple flu­ids with­in the body which were, yel­low bile, black bile, phlegm and blood.

This changed in the Mid­dle Ages when health became an exten­sion of our reli­gious beliefs, where a dis­ease was con­sid­ered a form of pun­ish­ment or a test of faith.

The renais­sance peri­od brought with it a pre­vi­ous­ly unknown lev­el of lit­er­a­cy with the print­ing of new inno­v­a­tive, or anar­chis­tic’ views spread­ing through the west­ern world with access to pre­vi­ous the­o­ries on health and med­i­cine’. This brought with it the enlight­en­ment’, or age of rea­son’ which includ­ed the work of many sci­en­tif­ic thinkers such as Fran­cis Bacon & Renee Descartes (16 – 17th Cen­tu­ry) and Isaac New­ton (17 – 18th cen­tu­ry). With this came care­ful obser­va­tions, sys­tem­at­ic col­lec­tion of data and math­e­mat­i­cal rea­son­ing, which we still embrace today.

This prac­tice applied to the study of med­i­cine and surgery. Remem­ber that surgery had mor­phed from bar­bers who would per­form small pro­ce­dures in their bar­ber shops. Be cau­tious when speak­ing poor­ly of anoth­er person’s par­a­digm or pro­fes­sion­al modal­i­ties start­ed somewhere!

“ Are we mak­ing peo­ple healthier? ”

This peri­od of enlight­en­ment bred the Bio­med­ical Mod­el of Health that cre­at­ed the sci­ence of bac­te­ri­ol­o­gy (Louis Pas­teur) and the sci­ence of cel­lu­lar abnor­mal­i­ty. It is still used today. A few inter­est­ing obser­va­tions for the health, fit­ness or the med­ical indus­try of today and per­haps a lesson.

Are we tran­si­tion­ing into anoth­er par­a­digm when one con­sid­ers that these models/​theories are sim­ply a reflec­tion of the peo­ple who cre­ate them?

Are we per­form­ing research on meth­ods that exist with­in their beliefs rather than par­a­digms and modal­i­ties that exist out­side the realm of our own practice?

Are we at risk of becom­ing a pro­fes­sion that resem­bles a self-lick­ing lol­lipop that serves to prove its own self-worth?

Sound harsh? This may explain why so many pre­vi­ous­ly proven’ treat­ment modal­i­ties have lat­er been over­shad­owed by a dif­fer­ent author who car­ries out research with slight­ly dif­fer­ent sta­tis­tics or method­ol­o­gy (9). Hence the lack of con­sen­sus with­in phys­io­ther­a­py when it comes to best prac­tice pathways.

With­in research, can we sim­ply manip­u­late sta­tis­tics, method­ol­o­gy and results to pro­vide evi­dence for our own per­son­al agenda?

To con­sid­er the best prac­tice path­ways that sup­port a par­a­digm can also have oth­er draw­backs. Such mod­els can lead to a dan­ger­ous over­sim­pli­fi­ca­tion or mis­rep­re­sen­ta­tion of real­i­ty, reduc­ing a com­plex process to a sim­pler one (9). This can be seen with best prac­tice path­ways for ten­don injury for exam­ple. Treat­ment can revolve around tech­niques that have been evi­dence-based with­out con­sid­er­ing oth­er tech­niques that might not have yet have been researched, either because no one has attempt­ed to, or because the ben­e­fits are so clear to see that no one has chal­lenged them. Per­haps a giv­en modal­i­ty has been over­shad­owed in a poor qual­i­ty research paper in the past? Even if there is no good evi­dence to dis­miss a cer­tain modal­i­ty, mud sticks and rumours trav­el fast.

The Alfred­son eccen­tric load­ing pro­gram was once the gold stan­dard and bet­ter than con­cen­tric or iso­met­ric. In fact, I remem­ber there being a sig­nif­i­cant judge­ment with­in our pro­fes­sion for any­one that dared to use any­thing oth­er than eccen­tric exer­cis­es. Look where we are now. A new per­son with a dif­fer­ent agen­da appears with dif­fer­ent research to sug­gest that iso­met­ric exer­cis­es are great for ten­don pain instead of eccen­tric, espe­cial­ly in acute management.

The same can be said for core sta­bil­i­ty. Smith et al (10) com­plet­ed a sys­tem­at­ic review with meta-analy­sis con­firm­ing that core sta­bil­i­ty is no more effec­tive than any oth­er gen­er­al exer­cise pro­grams. I remem­ber a time where one might be judged for not teach­ing trans­verse abdomi­nus and core sta­bil­i­ty for all con­di­tions from neck pain to ankle insta­bil­i­ty. There has been a grow­ing con­sen­sus for near­ly a decade that this par­a­digm may be detri­men­tal for LBP suf­fer­ers and this change in heart has been sup­port­ed by one of the orig­i­nal pio­neer of core sta­bil­i­ty, Peter O’Sullivan who now does great work pro­mot­ing an acknowl­edge­ment of a dif­fer­ent par­a­digm in the biopsy­choso­cial mod­el. What must be remem­bered is that these find­ings on core sta­bil­i­ty are spe­cif­ic to peo­ple with chron­ic non-spe­cif­ic low back pain’ only! Giv­en a screen­ing for psy­choso­cial issues such as a Start Back, the core sta­bil­i­ty par­a­digm may still be an effec­tive treat­ment modal­i­ty (no worse than oth­er modal­i­ties). It is a ques­tion of clin­i­cal­ly rea­son­ing the use of treat­ment rather than just treat­ing all patients the same.

So be care­ful when lay­ing your hat and faith in the cur­rent par­a­digm of med­i­cine that encour­ages only the evi­dence based’ treat­ments with­out space for well-rea­soned and anec­do­tal­ly suc­cess­ful treat­ments. This his­to­ry also teach­es us not to judge oth­ers with a dif­fer­ent par­a­digm to our own!

Blind Faith in author­i­ty is the real ene­my of truth.’ Albert Einstein.

Addi­tion­al­ly, these evi­dence-based find­ings often revolve around the Bio­med­ical Mod­el which assumes that all pain must be derived from one phys­i­cal source and The evi­dence does not sup­port this.

The Bio­med­ical Mod­el assumes that all pain must be derived from one phys­i­cal source and the evi­dence does not sup­port this.

We are enter­ing a new era of med­i­cine where we are increas­ing­ly embrac­ing the Biopsy­choso­cial mod­el, which in some ways can be in direct con­flict with the Bio­med­ical model.

This can be seen in the once-held view that pain is caused by a disc bulge, a car­ti­lage lesion, a lig­a­ment tear, a cam defor­mi­ty. The very same sci­en­tif­ic val­ues that brought the age of rea­son’ has also lead us to ques­tion our beliefs as we increas­ing­ly inves­ti­gate these struc­tur­al defor­mi­ties in healthy fit asymp­to­matic cohorts and find that they are just as preva­lent (11,12,13)!

So all of a sud­den, a disc bulge or a pos­i­tive pres­sure test­ing for com­part­ment syn­drome or a pos­i­tive blood test for rheuma­toid arthri­tis become so-what’? The disc bulge can now be seen as a nor­mal age-relat­ed change, just like grey hair. You don’t see peo­ple devel­op headaches just because they go grey or bald!

So we are forced to look out­side of the box to find an answer to the prob­lem, all the while prob­a­bly just mov­ing to the next par­a­digm that will then be replaced some­where down the line.

Specif­i­cal­ly, with­in fit­ness and rehab, we are rid­dled with par­a­digms from man­u­al ther­a­py, mas­sage, acupunc­ture, elec­trother­a­py, exer­cise ther­a­py which itself has had many dif­fer­ing ways of oper­at­ing and these par­a­digms can often move like the tide. It may be good to have many dif­fer­ent tech­niques at our dis­pos­al to make a per­son in pain more com­fort­able or an ath­lete more pow­er­ful. It helps if their appli­ca­tion is clin­i­cal­ly rea­soned, rather than treat­ing every LBP patient with the same modal­i­ties as the last, just because it is evi­dence based’ and part of a best prac­tice pathway’.

The age of rea­son’ is very use­ful to remem­ber in our own practice.

Just as we are chal­leng­ing our gener­ic beliefs on pain (11,12,13)

Are we chal­leng­ing our spe­cif­ic beliefs about med­i­cine with each patient?

Is everybody’s core’ weak? Ham­strings short? Or do we just assume that because they have back pain?

Do we ques­tion our obser­va­tions’ and test the body to assess if the person’s core is even weak in the first place? Is the joint even stiff? Is the merid­i­an blocked? If so, how is it weak? Where is it weak? In what posi­tions is it weak? Does that patient have poor beliefs about pain? How do you mea­sure your find­ings? Once you have deliv­ered the more spe­cif­ic rehab pro­gram to your client, has their func­tion changed? Has their pain changed? How have you mea­sured this? How effec­tive is your par­a­digm and your clin­i­cal reasoning?

There is one thing that I sug­gest you remem­ber. The rea­son you were drawn to the med­ical or exer­cise pro­fes­sion, (side from the illu­sion that we might end up being the next Eng­land foot­ball physio, meet a hand­some, wealthy doc­tor or be seen as an upstand­ing mem­ber of soci­ety) we want to help people.

Remem­ber that when peo­ple come to us for help, they are also in a sug­gestible state. Be care­ful with your words. Use your words wise­ly to help heal peo­ple. Use the Place­bo effect… it is not a dirty word. It is in every­thing we do, and as we move away from com­plete faith in the bio­med­ical mod­el, we have to accept that we can influ­ence peo­ple with our words just as much as actions. Imag­ine tak­ing an evi­dence-based rehab pro­gram and deliv­er­ing it to a patient with­out any enthu­si­asm or con­vic­tion. How effec­tive do you think that pro­gram will be?

If you make a per­son feel com­fort­ed, cared for and can allow them to believe that you can help them, then there is a good chance that you are already halfway there. Does it mat­ter whether we use acupunc­ture, elec­trother­a­py, man­u­al ther­a­py, mas­sage, S&C, Yoga? Our ego might believe this, but I’m not sure the Cochrane library would sup­port this view.

The age of rea­son’ is very use­ful to remem­ber in our own practice.

References

1. Hel­li­well .P.S, Abbott C.A, Cham­ber­lain M.A (1996). A Ran­domised Tri­al of Three Dif­fer­ent Phys­io­ther­a­py Regimes in Anky­los­ing Spondyli­tis. Phys­io­ther­a­py. 82(2):85 – 90.

2. Lang­ham­mer B, Stanghelle J.K (2000). Bobath or Motor Relearn­ing Pro­gramme? A com­par­i­son of two dif­fer­ent approach­es of phys­io­ther­a­py in stroke reha­bil­i­ta­tion: a ran­dom­ized con­trolled study. Clin­i­cal reha­bil­i­ta­tion. 14(4):361 – 369.

3. Hawkes J, Care G, Dixon J.S, Bird H.A, Wright V. (1986) A com­par­i­son of three dif­fer­ent phys­io­ther­a­py treat­ments for rheuma­toid arthri­tis of the hands. Phys­io­ther­a­py prac­tice. 2(4):155 – 160

4. David J, Modi S, Aluko A. A, Robertshw C, Fare­broth­er J (1998). Chron­ic neck pain: a com­par­i­son of acupunc­ture treat­ment and phys­io­ther­a­py. Rheuma­tol­ogy. 37(10):1118 – 1122

5. Hey E.M, Mullis R, Lewis M, Voho­ra K, Main C.J, Dziedz­ic K. S, Sim J, Lowe C. M, Croft P.R. (2005) Com­par­i­son of phys­i­cal treat­ments ver­sus a brief pain-man­age­ment pro­gramme for back pain in pri­ma­ry care: a ran­domised clin­i­cal tri­al in phys­io­ther­a­py prac­tice. The Lancet 365(9476):2024 – 2030

6. Cherkin, D.C., Deyo R. A, Bat­tié M, Street J, Bar­low, W. 1998. A Com­par­i­son of Phys­i­cal Ther­a­py, Chi­ro­prac­tic Manip­u­la­tion, and Pro­vi­sion of an Edu­ca­tion­al Book­let for the Treat­ment of Patients with Low Back Pain. New Eng­land Jour­nal of Med­i­cine.; 339:1021 – 1029.

7. Kuhn T.S The struc­ture of sci­en­tif­ic rev­o­lu­tion 3rd edi­tion. London:University of Chica­go Press. 1996

8. Hewa S. The com­ing rev­o­lu­tion in west­ern med­i­cine: A BioPsy­choSo­cial mod­el for med­ical prac­tice. Int review of mod­ern soci­ol­o­gy. 1994. 24(1); 17

9. Rus­sell L Soci­ol­o­gy of health pro­fes­sion­als. Lon­don: sage pub­li­ca­tions Ltd. 2014

10. Smith B.E, Lit­tle­wood C, May S. An update of sta­bi­liza­tion exer­cis­es for LBP: A sys­tem­at­ic review with meta-analy­sis. BMC Mus­cu­loskele­tal dis­or­ders (online). 20013. 15(416): 1 – 21

11. Brin­jikji W, Leut­mer P.H, Com­stock B, Bres­na­han B.W, Chen L.E, Deyo R.A, Hal­abi S, Turn­er J.A, Avins A.L, James K, Wald J.T, Kallmes D.F, Jarvik J.G. Sys­tem­at­ic lit­er­a­ture review of imag­ing fea­tures of spinal geden­er­a­tion in asymp­to­matic pop­u­la­tions. AJNR Amer­i­can Jour­nal of Neu­ro­ra­di­ol­o­gy. 2015. 36(4): 811 – 816

12. Chou R, Fu R, Car­ri­no J.A, Deyo R.A. Imag­ing strate­gies for low-back pain” sys­tem­at­ic review and meta-analy­sis. Lancet. 2009. 373(9662): 463 – 472

13. Ander­son J.C. Is imme­di­ate imag­ing impor­tant in man­ag­ing low back pain? Jour­nal of ath­let­ic train­ing. 2011. 46(1): 99 – 102