I saw this blog entry retweeted by a number of people that I follow on Twitter. It’s a well written blog post on the above-mentioned topic by Todd Hargrove, who is a writer and movement therapist. His story is quite interesting, he was an attorney who suffered from chronic pain but managed to eliminate his pain through self-education, lifestyle changes and movement therapies. He then decided to quit his career in law to help others with their pain and movement.
Todd has also published a book called A Guide to Better Movement: The Science and Practice of Moving with More Skill and Less Pain.
Back to the topic in question. Those who have been keeping up with the latest research would know the increasing scrutiny many surgical procedures for musculoskeletal pain have received in recent years. Many studies show no extra benefit for a number of surgical procedures when compared to sham surgeries. You can see the whole list of these procedures including surgeries for the knee, back and shoulder in this blog entry. What is even better is that you can find all the corresponding references all in one place.
Of course you can imagine the backlash some of these studies caused in the medical community. This is understandable and I think we in the physio profession know all too well, when many studies show the lack of effectiveness in many physiotherapy treatments. However it is something that all of us as health professionals need to accept, at the same time recognising limitations research studies can have. And as our understanding of different conditions improve, we also learn to better treat our patients bearing in mind the complexities of a disease and condition and the interactions of the whole person can have, biopsychosocial factors.
This is perhaps the first time researchers have asked the question whether a surgical procedure actually works after some procedures being routinely done for many years. As Todd points out at the beginning of his article, surgical procedures in general have not had to pass through the same level of rigour when compared to those required of drugs before they are allowed to be safely used for the general public.
Some surgeons have accepted the latest research and have changed their practice, which is great, because it’s fair to say that many patients have probably received surgeries that they probably did not need in the first place, for example shoulder decompression procedures for shoulder pain. And we know that surgeries bring its own set of problems, which is why surgeries should ideally be a last resort option for the patient.
However, despite all the available evidence telling us that a lot of these surgical procedures are no better than a sham, we cannot omit the huge placebo effect that surgeries clearly have on patients, at least in the short term. In the long term we know that there are no significant differences for many surgeries compared to conservative treatment. So in the short term surgeries even sham surgeries usually have a significantly better outcome than conservative treatment, so that is tricky part. Obviously we cannot conduct sham surgeries for patients in the real world. So the main thing here I think is education and fully informing patients with all the evidence so that they may make an informed decision. We need to accept that some patients may still want to undergo a surgical intervention, but they should make that decision with the full knowledge of its effectiveness in the short term and long term compared to conservative treatments.
How surgeons explain it to their patients is also very important. If you have heard Jeremy Lewis or Chris Littlewood talk about shoulder surgeries, you know what the surgeon tells the patients is of utmost importance, the typical advice of “try physio for a month and if it is not better, we will consider surgery” isn’t particularly helpful. This implies to the patient that surgery is more beneficial, and in many cases if the patient have been told that their rotator cuff is being “impinged” by the acromion, then in the patient’s mind they will be thinking “how will physio and exercise help that bone rubbing on my tendon?”. There is a lot more to be done globally it must be said, surgeons and physios should work as a team for the best outcome for the patient, and not in complete isolation to each other which is often the case. Whether we like it or not, a surgeon’s words carry much more weight than a physio’s, that’s just how it is, so surgeons need to bear that in mind and the great influence they have upon their patients.
At then end of the day, the cliché of putting the patient at the centre of care still remains the key issue for health professionals. Ultimately the patient has to make an informed decision provided we have given them the most accurate information concerning their problem. Being critical about what we do is the only way we can advance our profession both for physios or the medical community, it is something we need to embrace for the greater good of better outcomes for our patients.
I did not set out to write such a long entry, but it’s my two cents on this topic. Please click here to read Todd’s full blog post.