Thursday, 13 July 2017

Massage: Confessions of an ex-pro cyclist (Part I)

Photo: Soigneur

With the 2017 Tour De France in full swing, it may come as a surprise to many, that every team will employ 4 or more masseurs (known in France as Soigneurs) and virtually every rider in the race will take sports massage as part of their daily routine. I’ve seen a great deal written on the topic of massage over the years (here, here), not all of it complimentary (forgive the unintended pun). So, rather than discuss the topic from the perspective of a physiotherapist, I’m going to make my observations on the topic from the recipient or service user, in this case, the rider. I’ll try to explain what compels Tour de France riders’ to take sports massage at the end of each stage, despite what the science may suggest. 

Why? I hear you ask … well partly, because (in what seems now, like another lifetime) I spent a number of years as both an amateur and professional cyclist and have more than a few tales to tell. I rode and survived 2 Tours of Ireland, 1 Tour of Flanders, 1 Professional Tour of Britain, and a host of other single day and stage races, during a long and occasionally successful career in the UK and on the continent. So, in essence, I have felt the pain and suffering of elite level sport, and spent more than my fair share of ‘time on the table’ under the hands of some of the finest masseurs/masseuses in the business.  

By way of illustration, allow me tell you a story that remains most vivid in my mind, relating to massage … it was the 243km 5th Stage of the 1988 Kellogg’s Tour of Britain, from Birmingham to Bristol. Unusually for a long stage, the race started from the gun and the peloton (big group of cyclists) was soon strung out in a line as the pace shot up to 28 mph +. We were in for a long day of toil, because not only was the pace high (and we had 4 days in our legs already), but then the rains came down, and the hills around Cheddar Gorge loomed ominously ahead. 

As the race splintered, I soon found myself in a group of non-climbers and we clubbed together to form what is commonly known in the sport as the ‘Laughing Group’ or autobus. That is, a collection of riders who ride together to make it to the finish inside the time limit for the race (a rider has to finish within a set percentage of the time of the stage winner, and the limit is pre-set by the race directors). The laughing group has a leader who calculates the timings and ensures the group tries hard enough to get to the finish just in time so that riders do not get eliminated (thrown off) the race. To do that, we all had to take our turn at the front, chain gang style, and I still recall today the pain in my legs as the cold rain drenched us, the grit blackened our faces, and the hills sapped at our strength and morale. The captain had done his job well and we limped in with 3 minutes to spare. I rode straight to the team hotel where I dropped my filthy bike with the mechanic. I wearily made my way to my room, where I quickly showered and lay on the bed in a fitful sleep, still shivering from the cold and the effort.
I don’t recall how much time had passed, but I was awoken from my fitful slumber by the room telephone, it was the team masseur. “Hey Al, you’re next on the table” he announced, with his usual enthusiasm. All my body wanted to do was sleep, I could think of nothing else. “Erm, I think I’ll give it a miss today, I think I’m just gonna sleep this off”, I said, rubbing the grit from my eyes. “No no … you’d better come down, the guys said you looked a bit pale when you came into the hotel, we’d best take a look at you, come on down now, I’m just two floors below”. “OK” I said weakly, unable to fight my corner, “Ok, I’ll be down in 5 minutes”. As I rose from the bed, I felt like I’d left my body and soul somewhere on the road between Birmingham and Bristol and my legs by this time, were aching more than I’d previously recalled, ever before in my career, I felt broken and drained. Despite this, I called on my last ounce of resilience and took the stairs down to the masseur’s room. It was a peculiar masochistic tendency of mine, just to see how good or bad my legs felt … they felt BAD, and I limped onto the massage table, already dreading the next day.

Photo: Kelly and Roche back in the old days.
Without batting an eyelid, the masseur said, “Tough day Al?” I settled onto the table and wearily began to purge myself of the story of my terrible day. I explained nervously, that he’d need to take it easy, because my legs were caning me from the efforts of the last 4 days, the rain, the cold, not to mention the distance. “I know … I can feel it”, he said confidently. Already a qualified physiotherapist by this time, I guessed knowingly, that he couldn’t really … he was just saying that, to make me feel better. However, I sensed that he’d started his work with a much lighter touch, and gradually he worked away at the thighs and calves, focusing on the sore spots that he found, with his skilled hands and fingers. 

After a short while he broke the silence, once he knew that I had relaxed into the session, “Big day tomorrow Al?” he said. “What do you mean” I asked, suddenly jolted back into reality. “Westminster circuit race”, he announced with a jaunty grin. “Oh” I said, suddenly recalling that we had a 100km race in the City of London barely 15 hours away. “It’s your big day isn’t it? Your chance to get up there with the big boys?” he announced confidently. Referring to the fact that flat circuit races like that were meant to be my specialty. “Oh” I said doubtfully. “Not with these legs”. “We’ll soon have you ship shape” he replied confidently, as the kidology continued and he kneaded and wrung my aching muscles. I sensed that he spent a little extra time on my legs that evening, as he worked hard to return the ‘souplesse’ (French word for flexibility and suppleness) into those tired muscles, and I could feel the pain ebbing away. As he worked, he talked, and we discussed how the next day would go, how I would find the strength and ability to play my part in the race with some of the World’s greatest riders (Sean Kelly, Stephen Roche etc.). Finally he said “Were all done, Al” … “Go and get some food, now the colour has returned to your face”. I rose gingerly from the massage table after 30+ minutes, truly feeling like another man.

'The pain in my legs had ebbed away, I was no longer broken … in fact I was looking forward to tomorrow, the finale in London, I was going to the capital city to finish my first Tour of Britain, and I was going to make it count.'

The physio within me was not to be fooled though, I did the ‘stair test’ on the way down to dinner, and sure enough, I could go down the steps two at a time, in fact I literally skipped the last two (bravado, I know). As I did so, I spied Sean Kelly sitting (looking a little perplexed, at my little leap), at a nearby table, quietly finishing his dinner with his team mates. I gave him a little wink as a strolled confidently past his table … I said (secretly to myself) “see you tomorrow big fella”.

The next day went like a dream, we took the coach transfer to London, and I felt like I was floating on air, yesterday’s ‘laughing group’ legs were gone, and I took my place on the start line feeling strong and confident. I truly did ‘mix it with the big boys’ that day. The 100km Westminster stage was won by the classy Dutchman Jacques Hanegraaf, and Mr Kelly, well he came second, perhaps because I’d made his legs hurt with my hard turns on the front of the race (ha, ha … that’s my story and I’m sticking to it). I finished that stage in the top 20 (my only top 20 placing in the whole race), for me it was a minor victory. As we sailed over the finish line I was close enough to Kelly to give him a little ‘frotter’ (French, to rub or chafe … riders use this technique to move through the peloton), he laughed this time, and gave me a friendly pat on the back as we coasted along on the momentum of the final sprint, our day’s work done. 
Photo: Sean Kelly

The masseur was the first to come over and congratulate me, “You rode like the wind Al” he said with a massive grin. I was high on the adrenaline of finishing my first big pro Tour in such exalted company. I said simply, “Well, if it wasn’t for you … I would never have made the start line today … end of!” He laughed out loud, saying nothing at all. I shook his hand as hard as I could, knowing what his eyes were saying … he was just doing his job.
So what does this story tell us, I hear you ask? Well it’s a simple story of a lived experience of massage from the perspective of a sportsperson, which I felt worth sharing. I wanted to share it because it illustrates what an incredibly powerful tool, massage and ‘time on the table’ is for the competitive athlete. 

The therapeutic alliance between the athlete and the masseur/masseuse during that 30-40 minutes is thought by many riders to be as valuable as training and sleep in the preparation for competition.

The naysayers and the sceptics will of course insist that my experience (and those of all of the TDF riders) was/is either a one off or, entirely down to pre-conceived expectations and/or the theatre of placebo. To those, I would say that the experience of immediate post race pain relief, together with improved mood, occurred time and time again under of the hands of good massage therapists AND if it was placebo … frankly as a sportsperson, truly I didn’t/don’t care.

As a therapist you should milk it, because if it means the difference between your athlete being able to compete at their best the next day (or not), then get comfortable with that.

Retro Jerseys FOR SALE!
For those who suggest that as an athlete, I should have built my resilience and not be reliant on passive modalities (such as massage), I would politely explain, that the half hour on the massage table is where I was able to cast off my demons, talk trough the tough times, plan my tactics for the next day, work on my kidology and actually develop my focus, my social support and therefore DEVELOP my resilience. Massage uniquely combines the power of touch with individualised sports psychology, there is no time during a competition where the athlete feel so at peace, yet strangely empowered and motivated, than on that massage table. 

My advice to therapists who wish to work in elite sport, is this:

Understand that there is a demand for massage within elite sport

Learn and understand the power of 'time on the table' 

Learn and practice the skills of soft tissue massage

Decide for yourself whether knots and sore spots exist in athletes muscles

Know your athletes inside out

Know the sport inside out (including the tactics and kidology involved)

Understand and accept that your 'time on the table' intervention may have a strong element of placebo

Combine all those skills and knowledge and APPLY judiciously

Put simply, there remains a strong demand for sports massage at the top level of sport. It is an intervention that just might make the difference between the starters and the non-starters, the winners and the losers. 

BUT it is worth remembering … this therapeutic intervention is as much about what you say, as what you do. Think of it not JUST as massage but rather ‘time on the table’, a vital blend of therapeutic touch and sport psychology, dare I say it … a truly biopsychosocial intervention ... where the physical, the psychological and the emotional are all considered equally in a holistic ritual.

Finally, I’ll just remind those sniffy cynics and sceptics out there, that this article was written anecdotally from the perspective of the service user (in this case, the rider) and is simply a description of one single experience (of many), which attempts to explain why elite athletes have such a long standing and passionate affinity with sports massage, and as such, it is not a scientific treatise.
Racing in France taught me a great deal, not least an admiration of the beauty of the French language. So, as this article has been peppered throughout, with French cycling terminology, allow me to take this opportunity to regale you of my favourite French expression of all …

“Jamais, péter plus haut que son cul.” 

I'll leave the translation, this time ... to you!  

Sound advice for anyone, methinks.

Part II of this blog, will discuss massage from the perspective of the race Soigneur/Therapist and will consider the science behind the intervention … and THAT may reveal a different story completely?

Author: Alan J Taylor is a writer and critic who thinks about stuff and works as a Physiotherapist, University Assistant Professor and Medico-Legal expert witness ... The views contained in this blog are his own and are not linked to any organisation or institution. Like Bukowski, he 'writes to stay sane'.

Saturday, 3 December 2016

How to create your very own evidence base … in a post truth World

"At one time we had truth and lies. Now we have truth, lies, and statements that may not be true but we consider too benign to call false." Ralph Keys


Hurrah! I hear you say (unless you are a member of the AACP that is … acupuncture is not recommended as a treatment for back pain) the new NICE Guideline - Low back pain and sciatica in over 16s: assessment and management has just been published. That means a group of experts have successfully completed months/years of hard labour, poring through evidence to produce a thorough carefully worded (italics for emphasis) analysis and clear guidance.

Of course, it doesn’t stop there! Then we get commentary and analysis via bloggers. Here’s an example of a nice balanced piece by Neil O’ Connell who was a member of the guideline committee. KarenMiddleton added her view on how the guideline marks an important moment for the physiotherapy profession, emphasising the ‘opportunity to evolve and look again at practice and re-evaluate what is best for patients.’ … the guideline gives clear wording (italics for emphasis) on that, and naturally is disappointing for some, yet welcome to others.

Naturally, as is the way of the World, we get the bloggers, sceptics and Twitterati who also helpfully summarise the guideline, and it is here where things begin to get a little messy. What is clear, to us all in the ‘modern World’ is that there is little time to read long documents, and it is human nature to look for short cuts (so far so good). So in many fields such as medicine, pharmacy and physiotherapy we have the rise of the ‘infographic’ … 

Now, don't get me wrong here, infographics are brilliant, because they are short snappy and summarise long papers in one interesting and attractive figure. I you’ve never seen the work of Yann Le Meur … then you should. The artistry, accuracy and attention to detail, is both impressive and incredibly useful to visual learners. 


not all infographics … how shall I say … meet this exacting standard.

It became apparently obvious to me, that writing an infographic allows the writer to interpret something like a guideline, pretty much any way they want (just as Bloggers and internet commentators do), Herein, lies the rub …

IF the infographic writer, for one reason or another, chooses to alter the emphasis or wording, miss bit out, or get bits wrong … then the reader or recipient can be easily mislead. 

So, you end up with a snap-shot that can misrepresent the original document. Which of course, means that ANYONE can create their own version of the evidence base via the medium of the infographic.

HERE the fun begins!

Below I’ve written a short infographic (well ... some text and a picture) to help anyone create their own evidence base. If you follow the simple instructions, you can make any, paper review, guideline or article say exactly what YOU LIKE … it is a miracle! 

Try it yourself, adjust your favourite intervention, be it CBT, exercise, massage into a slightly bigger font or place on the positive side of the table/graph/pie chart in a slightly bolder colour etc. alter a word here and there (for emphasis/de-emphasis) and before you know it, you’ve changed the message of the original. You can even miss stuff out if you like, say radio frequency denervation or manual therapy (it is entirely your choice), if that’s is something you don’t particularly subscribe to.

Indeed ... if someone from the AACP had thought of it they could have re-inserted acupuncture into the LBP guidelines and lots of folk would never have noticed (cos’ they don’t have time to read the source document). That would of course, be disingenuous, but hey ... politicians do it daily, and we wouldn’t have had Iraq, Brexit or Donald Trump without a little (or more) distortion of the truth.

Were does this leave us? And why did I even bother to put pen to paper?

Well it requires us to have a realisation that we are in the ‘post-truth era’ as detailed so well by Ralph Keyes in his book The Post-Truth Era:Dishonesty and Deception in Contemporary Life. Keyes states:

‘At one time we had truth and lies. Now we have truth, lies, and statements that may not be true but we consider too benign to call false. Euphemisms abound. We’re “economical with the truth,” we “sweeten it,” or tell “the truth improved.” The term deceive gives way to spin.  At worst we admit to “misspeaking,” or “exercising poor judgment.”  Nor do we want to accuse others of lying.  We say they’re in denial.  A liar is “ethically challenged,” someone for whom “the truth is temporarily unavailable.”’ Ralph Keyes

Furthermore he states …

‘We can only understand the motives of such dissemblers by examining the sea in which they swim. Trends ranging from the postmodern disdain for “truth” to therapeutic non-judgment encourage deception. There is much incentive and little penalty for improving the “narrative” of one’s life. The increasing influence of therapists, entertainers, politicians, academics, and lawyers, with their flexible code of ethics, contribute to the post-truth era. So do ethical relativism, Boomer narcissism, the decline of community, and rise of the Internet.’

So there you have it folks … we have to adjust our radars, improve our awareness, be on our guard, even occasionally take the time to read a source document. Because, sometimes those nice folks who wrote that blog may just have written it to fit their own biases, or particular agendas, and in the same way, the handy visual snapshot of reality ... the infographic ... has sadly fallen foul of exactly the same concept. 

The dissemblers are amongst us, and I truly don't know why they behave that way.


Now  ... just a brief word on sceptics ... AND pseudo sceptics

The medical World has its fair share of sceptics or skeptics (as they are known in the USA), Ben Goldacre of Bad Science, is perhaps one of the most well known examples, Edzard Ernst is another. These brave souls, speak out on any issues from, basic bad science, global warming, Government policy, Prince Charles and his promotion of homeopathy, through to the risks of spinal manipulation etc. 

Good sceptics adopt an open minded approach and use science, debate, exposure (of bad practice) and apply critical examination and inquiry to all sides (including their own). 

Here's an example; Ernst has been a long time critic of alternative medicine (AM), and frequently adverse events (e.g. death after SMT) and general poor scientific practice relating to all sorts of disciplines within AM. These range from the more unconventional stuff like 'energy healing', and 'spiritual healing', through to say 'slapping therapy', and perhaps the more conventional, such as acupuncture. As such, he is commonly aggresively vilified and challenged by proponents of such therapies. His response is kindly, gentlemanly debate (often in the face of virtual abuse), use of science, critique, statistics etc. BUT when evidence comes along to challenge his World view on a topic, he has the good grace and conduct, to modify his view according to the developing and changing evidence base, or at the very least, air that evidence. 

Of interest to some physiotherapists (either historically or practically), MASSAGE had been a target of his for a number of years, until a new paper caught his eye and he wrote this and then later, this. Ernst is an example of how a GOOD honest sceptic is able to adapt their paradigm to new evidence and update their hypotheses to fit the data. In physiotherapy, SOME of our emerging breed of bloggers, podcasters and self-proclaimed sceptics are able to do that, and do it very well. SOME appear to default to the habits of pseudo-sceptics.

Pseudo-sceptics ... tend to:
  • Persistantly judge as false, and debunk anything that contradicts their paradigm.
  • Are partially interested in truth, evidence and facts, but MORE interested in defending their own views/stance.
  • May fail to update their paradigm to incorporate new evidence, and deny or bury data which doesn't fit their view.

Sceptic or denier?

'A sceptic will question claims, then embrace the evidence. 

A denier will question claims, then reject (or bury) the evidence....'

and for a brilliant commentary on pseudo-skepticism by Marcello Truzzi go here.

So be on your guard people … it's a tough environment out there, and distinguishing truth from fiction in a post-truth World ain't easy ... false news, pervades every aspect of the internet, even those sources, you thought you could trust, AND relies entirely on a passive (non-thinking) click of a button. Those who use it to their advantage know that, and you should too ... if you don't already! 

After all, that is what brought us Donald Trump. Good luck folks.

I’ll leave you with the wise words of Ralph Keyes who vocalises this much better than I ever could …

‘Post-truthfulness builds a fragile social edifice based on wariness. It erodes the foundation of trust that underlies any healthy civilization. When enough of us peddle fantasy as fact, society loses its grounding in reality.  Society would crumble altogether if we assumed others were as likely to dissemble as tell the truth. We are perilously close to that point.’ Ralph Keyes

Be careful out there folks … words matter, and semantics are important AND that is the TRUTH

HT to Woody  Guthrie for being an inspiration -  "It's a folk singers critical thinkers job to comfort disturbed people and to disturb comfortable people" ... see what I did?

Author: Alan J Taylor is a writer and critic who thinks about stuff and works as a Physiotherapist, University Assistant Professor and Medico-Legal expert witness ... The views contained in this blog are his own and are not linked to any organisation or institution. Like Bukowski, he 'writes to stay sane'.

Tuesday, 23 February 2016

Death following a neck injury: What can we learn from the case of Katie May?

This commentary was originally written as a general interest article for publication on a Web news page. For one reason or another it was not published ... So here it is, in a modified Blog format.

Katie May, a 34 year old Playboy model and entrepreneur, died on February 4th 2016 following a stroke. Whilst the details are sketchy, media reports of a neck injury during a photo shoot raises questions as to how a fit healthy 34 year old, could go from an apparent neck strain to a fatal stroke in a matter of days. This report takes look at the mechanisms of early stroke and considers what we can learn from the case.

Neck pain is a common complaint that is thought to affect around 10-13% of the population. However, most patients do not have a life threatening condition. That said the cervical blood vessels can be susceptible to injury. This was illustrated graphically by the tragic death of Australian Cricketer Phillip Hughes. Hughes died from a sub arachnoid haemorrhage (bleed to the brain) following a blunt injury to a blood vessel in his neck from a cricket ball.

The blood flow to the brain is carried by two small vessels at the back of the neck called vertebral arteries, and two larger vessels at the front, called the carotid arteries. The carotids carry around of 80% of the blood flow to the brain. It is well known that any of these blood vessels can be injured by trauma or affected by disease. It is well known that the early presenting symptoms of arterial dissection may be neck pain or headache and that ischaemic symptoms may not develop until later.

A complex anatomical region ...

So, how could an apparently fit, healthy female, suffer a stroke leading to death at the age of 34?

The complete picture of exactly what happened in this case remains unknown, but we can learn from past experience. There are a number of potential scenarios.

One scenario is that like Phillip Hughes, Katie May had perfectly HEALTHY blood vessels that were injured internally (arterial dissection) by an ‘awkward’ fall during a photo shoot. What happened thereafter remains open to speculation. At that point ANY intervention whether it was advice (to keep moving), pain management/education or manual therapy/manipulation, may have ended with the same outcome.

It remains unexplained how some dissection pathologies resolve yet others go on to lead to stroke or death. It is thought that this may relate to variety of intrinsic conditions linked to connective tissue disorders and clotting factors. In addition, extrinsic factors may also play their part. A failure to recognise the signs and symptoms (assuming there were any) of a developing pathology in accident and emergency, at the GP practice, or under the care of a musculoskeletal therapist (Physiotherapist, Osteopath, Chiropractor) may be also be associated with fatal consequences. A common medico-legal scenario, is a delay to appropriate triage, in order to commence a trial of management or specific treatment.

 Thrombotic stroke - image en.wikipedia.org550 × 800Search by image 

A second scenario of many, is where a person develops musculoskeletal neck pain insidiously or via a minor trauma and seeks the attention of a manipulative therapist, such as a Chiropractor, Osteopath or Physiotherapist. Katie May Tweeted that she was going to see her Chiropractor, though no detail has been released. However, the wave of assumption and speculation implicating Chiropractors, could well be entirely unfounded as this single case study clearly illustrates. 

The status of the blood vessels at the time of ANY consultation, may be either healthy OR unhealthy. Unfortunately, without sophisticated equipment, there is no way of knowing whether vessels may be ‘weak’ or suffering from underlying disease such as fibromuscular dysplasia or atherosclerosis (rare in the younger patient). This is one of the reasons that manipulation in particular, has been called into question. At best the science remains equivocal. A recent systematic review found no association and suggested that, "the relative risk of ICA dissection after cervical spine manipulation compared with other health care interventions for neck pain, back pain, or headache is unknown". However, critics argue that spinal manipulation to the neck may injure vessels, leading to stroke.

Neck manipulation has many descriptions, but generally involves a high velocity manoeuvre, outside the control of the patient, which may produce a click or crack. There is evidence to suggest that for acute/subacute neck pain, cervical manipulation provides better pain relief and functional improvement than medications such as varied combinations of NSAIDs, analgesics and muscle relaxants. However, the caveat is that this benefit, may not be entirely risk free. Furthermore, it is suggested that the actual number of adverse events (injury, stroke, death) may be massively under reported


Could the risk be reduced?

The debate on the safety of manipulation has not been helped by the lack of agreement on the risk of blood vessel injury following treatment. Some reports suggest ratios between one in 50,000 to one in nearly 6 million manipulations, though as mentioned, many question the accuracy of this data, citing up to 100% under-reporting. A review of 134 case reports, published in 2012, said, “there was potential for a clinician to prevent 44.8% of adverse events (such as stroke or death) associated with manipulation”. The authors suggested, “10.4% of the events were unpreventable”. Interestingly, the patients who died had continued or excessive spinal manipulation, despite the fact that they were not responding to treatment, or their symptoms were worsening.

Despite RCT reports that in apparently healthy vessels, manipulation to the atlanto-
axial joint does NOT appear to increase mechanical stress on the vertebral artery, it remains unknown what the affect might be on diseased, weak or already dissecting vessels (vertebral or carotid).

As it stands, scientific knowledge can neither accurately quantify the risk associated with neck manipulation, nor establish an unequivocal link between manipulation and adverse events. A 2016 physiotherapy publication, a profession that has been prominent in the field of neck risk assessment, suggested that, at best, “early recognition of injury to blood vessels” may reduce the occurrences of inappropriate treatment. This raises the important question of what exactly is 'inappropriate treatment'? Whilst manipulation may have been demonised by some, it is important to understand that blindly defaulting to ANY favoured intervention in the absence of sound clinical examination and risk assessment ... may lead to adverse outcomes in the presence of arterial injury.

Could tragic events like this be prevented?

Disappointingly, the complexity of the human body and mind, dictates that the answer will vary from case to case and clinician to clinician. It remains essential for ALL CLINICIANS to retain an index of suspicion for arterial injury in cases of trauma, be cognisant of ‘red flags’ and apply appropriate clinical reasoning and examination procedures. A default to, a single school of thought or approach (whatever that may be), may lead to delays to triage, inappropriate management and potential medico-legal consequences. 

Atypical, worsening presentations, with OR without subtle ischaemic symptoms may alert the clinician to the presence of arterial injury. The diagnosis of arterial dissection rests on a careful clinical history, physical examination, and targeted ancillary investigations. Clinicials should be cognisant that delay may be fatal.

What do we all have to learn from cases like this?

1. Retain an index of suspicion for vascular injury in trauma cases. 

2. Know your anatomy and pathophysiology.

3. Hurt does = harm, in some cases

4. Examine and question the patient in detail.

5. Have, and retain vigilance for ‘Red Flags'.

6. A DELAY to appropriate management, is a common root cause in many medico-legal cases.

 ... There is NEVER absolute certainty


HT to Woody  Guthrie for being an inspiration -  "It's a folk singers critical thinkers job to comfort disturbed people and to disturb comfortable people"

Author: Alan J Taylor is a writer and critic who thinks about stuff and works as a Physiotherapist, University Assistant Professor and Medico-Legal expert witness ... The views contained in this blog are his own and are not linked to any organisation or institution. Like Bukowski, he 'writes to stay sane'.

You'll find him mostly on Twitter

Wednesday, 28 October 2015

Forget models, mantras and gurus ... Listen to the patient

The current debate in Physiotherapy about the use and misuse of evidence based medicine (EBM) was well and truly polarised by Roger Kerry's recent Evidence-Based Physiotherapy: A Crisis in Movement.

In a brilliant no holds barred polemic, the author called made a plea for sanity in a World gone mad. It got me to thinking. I've long been an advocate of big picture thinking, and puzzled for many an hour and longer about why we think the way we do. Why for instance, physiotherapists got fixated with the vertebral artery, back in the day when spinal manipulation was all the rage. It slowly became apparent that there was more to cervical vascularity than just the vertebral arteries. Hence the development of a system based approach to the issue which focused on movement (not JUST manipulation), all of the vascular system (not JUST the vertebral artery) and all of the potential pathologies (not JUST dissection).

The result was a risk assessment framework which offers sound guidance and direction for those offering any movement based interventions (including assessment) for patients with head and neck pain. The IFOMPT document is not a guideline, rather a framework for THINKING, for clinical reasoning, and directs clinicians to make decisions based on the big picture. It exhorts clinicians to familiarise themselves with cranial nerve testing, surprisingly, (and perhaps alarmingly) not part of the skill set of many PT's, and to consider blood pressure as an additional risk assessment tool. None of this was rocket science BUT, it was perhaps an example of restricted thinking, dominated by the 'experts' of the time.

The new 'experts' of our time are the social media commentators, the 'institutes' the 'organisations' who shape our opinion with their interpretation of EBM. Many seem to shout loudly (and with significant bias) from the roof tops about what we should or shouldn't do. It is a fascinating dynamic, which I have observed from both within and afar. When internationally respected pain expert Mick Thacker wrote a guest editorial recently for Pain and Rehabilitation - the Journal of Physiotherapy Pain Association, he upset the apple cart. He challenged the use of 'mantras' and singular thinking with another brilliantly written piece entitled 'is pain in the brain?'  His commententary, that he was surprised that such views about pain were "…so widely accepted by physiotherapists considering our backgrounds", caused outrage in some quarters and he was was vilified on social media by disciples of the pain/biopsychosocial model. They argued their case with such tactical vigour, you would have to conclude they could not be wrong …. unless of course, you were thinking.

It is perhaps the absolute certainty of some, that I find most fascinating and perhaps a little dangerous.

It is time, as my colleague so rightly said, that we all begin to think for ourselves.

Image via

There's no doubt that the biopsychosocial model has much to offer and only a fool would deny its role and value. But should you throw yourself at its alter? The biomedical model has many limitations, that are well recognised.

But when a patient presents with a worsening scenario, it is worth remembering that not everything is a 'flare up' and just as 'hurt does not always equal harm' ... SORRY but, sometimes it does!

Similarly, whilst modern science suggests most patients with LBP for instance don't require scans or X rays … some do.

It remains our job to be able to recognise those cases and manage the others with whatever skills we have left at our disposal. Otherwise, a sheep like adherence to one particular school of thought may prove to be our undoing. We need to know examination skills, we need to know pathologies … we need to know when scans or triage are appropriate, we need to know the limitations of our own thinking, all these things matter.

I decided to illustrate my point with a cute story ... which nicely illustrates the shortcomings of both 'models' and how we truly have to listen to our patients and put aside our preconceptions.

Mr Xrayspecs (a 52 year old builder and hobby cyclist) walked into my clinic recently, referred from another Physiotherapy colleague. He presented with a description of chronic lower back pain and non specific left leg pain.

I introduced myself and asked him why he'd come to see me.

"Well, I have this pain you see, and I think it's getting worse, so my physio sent me to see you … seems to think you might be able to help" he said, somewhat doubtfully.

"Tell more about it " I asked.

"Well it all started 34 years ago". "34 years", I mirrored and sat back in the chair ready for the long haul.

"They've tried everything" he went on. First, when my leg started aching (aged 18), they said I had a trapped nerve 'sciatica' they called it. They said I'd got an asymmetry. They gave me lots of treatment, you know manipulations and stuff but nothing worked. Then I went to the osteopath and he put all my joints back in … but that didn't work either."

It was a familiar story ... one I've heard (probably like you) many times before.

He went on "I just tried to ignore it and carry on riding my bike, but the pain came on every time and my leg felt weak."

Oh, so you felt it whilst you were cycling did you?" I interjected. "YES", he reiterated with some agitation. "Tell me more", I asked, ... "They said I must be trapping a nerve or something, probably because I was bending forward, on the bike". "Oh" I said, thoughtfully. "Then they sent me for a scan, but nothing showed up". 

He continued, "I was getting really fed up I can tell you, and about 3 years had gone by". "OK, I can understand that" I said compassionately. "Then what happened" I asked. "Well, thats when they said it might all be in my head" he said (his words). "They sent me to a pain clinic, gave me some injections and told me I should self manage it, but I knew something was wrong". "Oh" I said, brilliantly … pausing for dramatic effect.

"What did YOU think was wrong" I asked. "Well I didn't know what exactly ... but I knew my leg wasn't right, it felt weird, weak, strange, but when I started to say that, I think they thought I was a bit mad, so I backed off a bit". "Oh" I said again, somewhat repetitively, but he carried on regardless.

"I've been to every specialist you can name, orthopaedics, sport, pain, physios, osteopaths, chiropractors, masseurs, you name it, I've been there". "And" I said, probing hopefully. "Well its just getting worse and now I've got back ache too" he continued. "They sent me for more scans recently and I've got wear and tear and disc degeneration now ... and they said that must have been the problem all along".

"So now I'm labelled with chronic pain and I'm having CBT and all that psychological pain education stuff". "Oh", I said hopefully. "Yeah but that's a waste of time, just like the rest of it was … pacing whats that gonna do? Mindfulness? I'm a bloody builder … I'm getting worse, not better and NOBODY LISTENS", he said, pausing for effect.

"What do you mean" I said. "NOBODY LISTENS" he said again, somewhat menacingly.

Image via -

I leaned forward, listening intently with wide eyes. "Look when it all began, it always came on when I was exercising, and it still does, like when I ride my bike, or push a wheelbarrow on site or go up the steps to the roof … I might have back ache now but I didn't before and my leg still feels like it's got no blood flowing into it. To be fair I've been saying that for 34 years but everyone glazes over … Its like they only want to fit you into their bag, their particular pet theory".

At that point I laughed out loud. "It's not funny" he said. "No, no" I apologised, "I'm not laughing at YOU, I'm laughing at me ... US!" I stuttered.

"What do you mean" he demanded. 'Well" I began, " I think my colleague may have sent you to see me because he thinks I may have a pet theory too" … It went quiet … I took up the cudgels.

"When you said that your leg felt like it had no blood going to it, did anybody test for that." I asked. "No" he said, "they just kept talking about nerves or discs initially, then chronic pain and CBT and how 'pain is in the brain' and stuff, like I explained." he said.

I asked a few more probing questions about the nature of his pain and asked him to lay on the couch.

I took his lower limb pulses - Normal.
I took his brachial blood pressure - Normal.
I took his ankle blood pressures - Normal.

I asked if he was still riding his bicycle and if his pain still came on with cycling. "Yes" he said, "as regular as clockwork … as soon as I get to 145 bpm on the heart rate monitor." "Oh" I said. "Can we ask you to exercise to that level I asked'?

"You can bloody well ask me to do what you like if we can get to the bottom of this bugger" he said cracking a smile for the first time. I explained that we may find nothing at all, and asked him again if wished to continue with a simple exercise test. He was already climbing eagerly onto the exercise bike and adjusting his pulse monitor belt.

The exercise test quickly reproduced his leg pain as predicted, as soon as he reached around the 145 bpm mark. I pushed him a little further… 165 bpm "Yes", he said with some satisfaction. "Now my leg feels funny, weak, like theres no blood going to it".

He jumped off the bike and we lay him on the couch … we replaced the left and right BP monitors onto the ankles and inflated them, they ran simultaneously.

At minute 1 (post exercise) the systolic brachial BP was 185 mmhg

At minute 1 the right ankle systolic BP was 160 mmhg. The left recorded nothing (I waited … I'd seen this before) ... the BP can be lower than the machine can record.

At minute 2 the systolic brachial was 180

At minute 2 the RIGHT ankle BP = 155

At minute 2 the LEFT ankle BP = 70 mmhg 

Post exercise ankle brachial pressure index (ABPI) was calculated as 70/180 = 0.39

The published cut off point for post exercise ABPI is currently 0.6 (Peach et al, 2012)

I'd turned the BP monitors away from his gaze … He was anxious to know the result.

I explained that he would no longer need to continue with the mindfulness and CBT.

He was referred to the vascular surgeon with a full outline of the consultation and test results.

4 weeks later (after the tests had been repeated the vascular clinic) magnetic resonance imaging of the arteries revealed a significant flow reduction to the left lower limb in the region of the external iliac artery.

The patient underwent a 5 hour vascular surgery (longer than expected due to the complex intra-operative findings) involving endarterectomy and shortening of a 'significantly tortuous artery'.

He made a full recovery and 6 months post surgery reports NO LEG PAIN under any conditions, including exercise. He still gets intermittent low back pain, which he considers to be "normal".

His post exercise ABPI measures have returned to within normal limits (> 0.6)

He has returned to full function work/cycling/running/skiing with NO LEG SYMPTOMS.

For various reasons linked to clinical reasoning and therapist/physician beliefs ... it took 34 years to get to the bottom of this case.

For an analysis of quite how that could be ... try a stab at the 5 Whys of ROOT CAUSE ANALYSIS 

What do we all have to learn from this case.

1. Listen to the patient

2. There are limitations of BIOMEDICAL reasoning

3. There are limitations of BIOPSYCHOSOCIAL reasoning

4. NEVER have blind faith for 1 paradigm

5. Know your pathology


7. N=1 (it REALLY does)

8. It's OK to be discombobulated ... Just say "Oh"

 ... and just for the record, there is NEVER absolute certainty.

Image via Steven Shorrock

Author: Alan J Taylor is a writer and critic who thinks about stuff and works as a Physiotherapist and University Assistant Professor ... The views contained in this blog are his own and are not linked to any organisation or institution. Like Bukowski, he 'writes to stay sane'.

You'll find him mostly on Twitter
... that is until, he finally deletes his account, or is 'evidence based blogged' to oblivion.