A Unified Theory of Healthcare - How it all links together (Part II: Barriers to rehabilitation and common health care myths)


by Andrew Davidson

 

This article is the second of a three part series on healthcare in the UK. The first piece explained the complexity of common presentations and presented a critique of prevailing paradigms. These articles form the foundation for a PhD proposal looking into reviewing and updating the biopsychosocial model, and asks whether it is possible to create a unified theory of health care.

 

As usual, all statements are backed up and references are available upon request. For any non-healthcare professional reading this, this article is not to be used as a guide for how to treat your back pain - if you think you have any of the symptoms you may read below contact your GP and get a referral for physiotherapy.

 

 

Common healthcare beliefs - culture and value dependent


As lower back pain is the most common chronic musculoskeletal disorder in the world there are many different opinions on how it should be managed. In the UK we have the National Institute of Clinical Excellence (NICE) who reviews data for the treatment of various conditions and produce a paper known as a ‘core standard or best practice’ guideline which indicates what treatment should be provided. Despite the fact that the guidance is based on research chronic musculoskeletal disability levels have increased by approximately 30 % since 2005.


As discussed in the initial article, musculoskeletal disabilities such as back pain will affect a person’s entire life; their sleep, mood, relationship with friends/family/partner, finances, work, exercise, weight, cardiovascular health etc. As a result there are several common health care myths that have prevailed over the last 10-20 years. It is not the intention of the author to offend any health care professionals with different approaches to physiotherapy, but merely to engage in a scientific debate and provide education and advice on recent evidence that practitioners may not be aware of.


Healthcare beliefs will vary depending on culture and country - for instance some cultures struggle to define pain as they do not have the same vocabulary to express their symptoms as English (no other language has as many words to describe the experience of pain). As a result they have compensated by expressing their pain physically through adapted movements, mannerisms, sadness, anger, frustration etc. Similarly some cultures consider pain as a vital sensation which can allow for transcendent experiences. For simplicity this article will deal with prevailing health care beliefs in western medicine.

 

 "I don’t use medication, it's dangerous for you and I prefer to stay natural."

 

This is a common belief amongst patients which in itself isn’t a problem as long as it isn’t based on misinformation. I do not wish to enter into a long debate about alternative medicine, but people should be aware that there are practitioners who will try and take advantage of people in pain and will try and sell you ‘natural remedies’ with no demonstrable medicinal effect. If a doctor or independent prescriber has provided you with a prescription to help reduce swelling and pain it is not simply to make you feel better, but will assist your recovery and help you avoid common compensatory behaviours such as limping, avoiding bending or stretching, grimacing, fear avoidance etc. To give an example, if you sprain your ankle it is normal for you to have a week or two of an altered walking pattern while your tissues heal, applying ice and taking some simple medication via prescription or pharmacist and doing some gentle stretches is a normal part of recovery. If you are still limping after 6 months your problem isn’t the ankle, but the maladaptive movement pattern you have adopted. Rehabilitation from this point of view is much more complicated, as the fear of weight bearing has now become a barrier to rehabilitation. This is then addressed through developing an understanding of how persisting pain works.  


It is worth listening to Australian Musical Comedian Tim Minchin’s beat poem ‘Storm’ when it comes to what is ‘natural’ as everything is made from chemicals; aspirin for instance is derived from the bark of a willow tree. There is nothing wrong with choosing to not take medication, it’s just better to educate yourself and make sure you are doing it for the right reasons or you may become the victim of fraud.

 

"More care is better care, it’s better to be on the safe side and investigate just in case there is anything wrong" More commonly: "I might have a slipped disc, I need a scan to be sure."


This belief often manifests in the desire for a specific sort of attention from the health care professional in order to feel that the problem is being taken seriously. A classic example is having a sprained back and wanting an MRI scan to ‘see if anything is wrong’. This was touched upon in the previous article in the form of the new 21st century diagnosis VOMIT - (victim of modern imaging technology). Without reiterating the entire article - it is common to feel worse after a scan regardless of what it says as the majority of people in the pain free population have natural changes.


The body is much like a car and will show signs of wear and tear and use without necessarily affecting function. 67 % of pain free patients show disc bulges in their lumbar spine with absolutely no change in function or strength. Less than 1% of back injuries actually require joint scans, so how do we know which ones need it and which ones don’t? It is all based on symptoms and clinical examination. Pain alone is not a predictor of damage, or rather, pain alone does not mean that there actually has to be any damage. Pain is a highly complicated experience and involves multiple systems acting at the same time. A qualified practitioner will be looking for ‘red flags’ to determine if a person actually needs a scan - as an example some of these include; bilateral pins and needles and numbness in both legs, urine or fecal incontinence, night sweats and unexplained weight loss, progressive non mechanical pain etc etc. The best predictor for how well a person with back pain will do is how they perceive their own disability level and if they are positive or negative towards their future rehab (See the StaRt back tool).

 

"I’ve just injured my back, It’s important that I take time off work to rest and recover".


While this is a tempting response (and there is no harm in taking a day or two to let the initial acute injury settle) the best thing to do after a back sprain is to use ice and some simple medication from the GP or pharmacist and to start gentle movement as soon as possible. Over 90 % of back injuries are simple back sprains which is where there is simple trauma to the muscles in the back. Muscles are relatively simple structures in that they have plenty of blood supply, but they require movement and blood flow to heal properly. By lying down / avoiding movement for an extended period of time you increase the risk of weakness/stiffness/tension as well as pain, poor sleep and needing more time off work. Occupational health research has shown that if people are off work for more than 6 months there is a 50 % chance they won’t return at all. The problem is then often exacerbated by anxiety, low mood and worry about the future. This can form a very strong maladaptive barrier against movement and by the time people are finally referred to a healthcare professional these beliefs often need to be dealt with first before movement and rehab can begin.

 

"My disc has slipped out, you need to pop it back in again."

 

Discs are surprisingly sturdy structures, there are different types of disc injuries but it does not really ‘slip out’ of position. The most common injury is if the membrane (annular ring) of the disc weakens over time and the inner substance of the disc pushes up against this weakened area. This produces a small balloon protrusion and may put some pressure on surrounding structures. There is a theory by McKenzie that certain exercises and therapies can push the disc back in, but new research dismisses this as effective care for back pain, predominantly because it is again single minded in its approach and as mentioned above; most people have disc bulges without pain. To claim that fixing the disc will fix the back pain is a fallacy, the majority of back pain presentations heal with time and simple care, but those that do not are rarely related to the actual disc itself. It is possible to see a reduction in a disc bulge size after several weeks of rehab if one were to scan pre and post treatment, however this is an expected response from the body’s natural anti inflammatory healing process and is simply the disc and surrounding tissue reducing its swelling from the initial trauma (just like a swollen ankle reduces in size after a few weeks).

reduction in disc bulge size

Example of reduction in disc bulge size and volume after 3 months.

 

"A disc injury is for life - I’ll need surgery and might end up in a wheelchair just like (insert name of relative)."


No it’s not and no you won’t. Nobody has ended up in a wheelchair because of a disc problem, but it is common that people's perception of their own disability worsens the longer the pain persists for just remember - pain does not mean damage.

However the feeling and depression associated with back injuries often leads to worsening pain and mobility over time but that has nothing to do with the actual disc itself. Having worked in a chronic pain department for a few years I have been fortunate enough to study a highly complex population - if an empathetic and holistic approach is taken and treatment is value based and personal for the patient everyone can improve their symptoms regardless of what scan results say. Surgery is very rarely needed for back pain and in cases where surgery has been prescribed for disc bulges post op recovery rates are very poor, whereas the natural history for herniated discs are actually very good.


"Cracking your joints is bad for you."


Commonly known as synovial joint cavitations (SJC), cracking your joints is the results of nitrogen gas being compressed and released within the joint. This can often free up joint space for a short while and relieve symptoms, however it is worth noting that this is only a short term treatment and does not treat the underlying cause of a problem. There is (as far as my literature review has revealed) no evidence to suggest SJC are harmful with the only exception being in the neck. There is a small increased risk of vertebral artery injury, fracture, sprains and in rare occasions death if done incorrectly (I would personally argue you can achieve similar results with mobilisations with no associated risk).


However there is some data to suggest repeated and regular cracking of joints, particularly in the thoracic (mid) spine can attribute to unhelpful health behaviour where the person feels they have to crack their joints or they won’t feel / get better. In general, there doesn’t appear to be any evidence to suggest the occasional release of synovial joints through stretching or warm up is harmful. If it hurts while you’re doing it, stop doing it for a while. If pain persists, see your doctor.

 

"My back is out of alignment, you need to click it back into place."


Scoliosis is rather poorly defined as ‘an abnormal lateral curvature of the spine’. It is a presentation which may or may not have pain or symptoms associated with it, and it is important to know that just like disc bulges there is a significant amount of people in the pain free population walking around with a scoliosis without being aware of it.


Despite this some people without any evidence of a scoliosis may still be told by their health care professional that their back is out of alignment (without being too controversial this is a common healthcare belief amongst chiropractors). To state it simply; there is no evidence to suggest there is a ‘normal back alignment or posture’ that everyone has to adhere too, and furthermore there is no evidence to suggest back pain can be ‘fixed or cured’ by spinal manipulations. Not to be misunderstood, manipulations may very well be used as a treatment to help with range or pain in the short term, but under no circumstances are backs being placed back into alignment. African caribbean populations statistically have a larger lumbar lordosis that white british populations making their postures and alignments completely different, yet the prevalence of back pain is equal amongst them both, every single back in the world is anatomically slightly different!

 

"It’s probably arthritis, my mother has it and she needed a knee/hip/shoulder/head replacement."


Arthritis is unfortunately a very unhelpful and regularly misused term. It directly translates to joint swelling - (and that is all it means). An ankle swelling up after an injury could cause some inflammation in the joints of the foot, however this is not an ‘arthritic’ condition. Rheumatoid arthritis is a very specific systemic disease that affects the whole body and is often diagnosed at a relatively young age and is associated with shorter life span and reduced quality of life. Osteoarthritis is a completely normal part of the aging process and is as common as greying hair and wrinkles. Sometimes it can be painful and it may be seen as a reduction of joint space on an x-ray, however just like disc bulges a significant portion of the pain free population show changes on their x-rays without any symptoms, (this even starts to show after the age of 25). Osteoarthritis is not hereditary but is a result of multiple factors such as age, weight, height, trauma over time, previous injury and general activity levels. Having ‘moderate or severe’ osteoarthritis on your scan does not mean that you will need surgery or a joint replacement. At present the current criteria for joint replacements includ; being over 65, constant pain, disturbed sleep, failed physio, failed previous surgery, failed medication, regular giving way or locking and significant impact on work and personal life. A replacement lasts for about 10 years and it is worth leaving for as long as possible and trying all other interventions first, even several times if possible.

 

Other day to day beliefs (just to end on a happy note):


Eggs are bad for your heart

Bah and humbug - egg yolk does contain cholesterol but eating one or two eggs a day will not raise the risk of heart disease, particularly compared to for instance processed food high in fat. In addition they contain complete proteins, vitamin b12 and vitamin D and iodine which can help with thyroid function.


Being cold can give you a cold.

Bah and humbug 2 - people are more likely to get sick indoors where germs are easily passed. There is data to suggest people who spent several hours in temperatures just above freezing had an improved immune response to fighting viruses.


There are many more beliefs that persist (this article doesn’t even touch on anti-vaxxers, homeopathy or the constant peddling of different pharmaceuticals for made up conditions by drug companies) but it has given some insight into common beliefs you are likely to face in western medicine. Part three will introduce the topic of healthcare inequality and discuss what changes will need to occur in western society to reduce musculoskeletal disability rates, improve employment rates, reduce prescribing of medication/surgery/injections and scans and truly introduce a holistic approach to injury and pain.


Any questions, please head down to the comment section - hope this was informative and didn’t rub anyone too much the wrong way!

 

Andrew