The Paradigms of Rehab & Medicine

David Barrow

Rehab Guru Co-Founder

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 – 18thcen­tu­ry). 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. AJNRAmer­i­can 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

< PrevblogNext >
David Barrow

David is a Physiotherapist who has been involved in Professional Sport, battlefield trauma, chronic pain and the NHS. He continues to work clinically alongside his development role in Rehab Guru. David is passionate about Health tech to transform outcomes for patients

David Barrow

Rehab Guru Co-Founder