Why aren’t we turning the light switch off more?
Remember the Clapper? “Catchy jingle” is how Morgan Freeman described it in Bruce Almighty. A simple device applied to a light switch that is designed to turn the light on or off when a clapping of the hands happens. Super popular in the 90’s. “Clap on…Clap off….the Clapper”. Got me thinking after I saw that the clapper was still available for purchase…what if…as rehabilitation professionals we were able to turn off a client’s symptoms during their visit instead of producing them? What if…we were able to do that and then show the client how to reproduce that themselves? Now I’m not talking about avoiding pain. I’m not even talking about talking it easy on our clients in rehab sessions by not having them work hard or achieve muscular fatigue during exercise. But rather, I’m suggesting, that as part of an assessment tool, we try to determine if the use of forces around the body with our hand, education, postural changes, belts, etc, can turn the symptom ‘off’ instead of ‘on’. What information would that give us if we could do that? With all the social media ‘disruptors’ and challengers out there (nothing wrong with it), it seems like we’re being convinced that we haven’t gotten ANYONE better in the past 50 years! Successes that we have seen appear to be merely a fog curtain of Hawthorne effects and placebos. Our biggest challenge in healthcare is NOT the mechanisms of how we get people better. Not even the application to get to the mechanism. Our biggest challenge is the clinical thought process of why we do what we do! In 17 years as a physio, I’ve gone through the doldrums of success and failure. I’ve convinced myself that I was top of the food chain, and sweated the disbelief of letting my patients down of not achieving their goals.
One of my biggest epiphany however came from the realization that I could get just as much (if not more information) about my patient from attempting to eliminate their symptoms alongside trying to stimulate them. @Keyclinicalskills refers to this as “Light switch off”. By turning my attention away from “does this hurt”, “ooooo this feels restricted” and the ever loved “this end-feel feels tight”, and focusing on “do your symptoms change when I do this?”. Recently published studies have even demonstrated dramatic changes in cerebral processing are being seen with fMRI just by changing the words we use and the focus we place on movement (found here). I have found several things have happened when I attempt light switch off testing and treatment. 1) I automatically engage the patient! Positively! Establishing a therapeutic alliance is becoming more documented in the literature and is defined as the working rapport or positive social connection between the patient and the therapist
(found here). 2) Buy in from the patient. We have established our profession as the “Physical Torturists” or “Personal Terrorist”. All lovely titles! From the outset of rehabilitation in the physical therapy setting, some people are automatically expecting pain when they come in for their visit. “Just do what you have to do” resonates throughout clinics across the globe as we have convinced people the only way to get better is through trial by fire and pain! Why is this? Are we finding justification through experience and research that lightly suggests that painful treatment are better than non? Have we given up on the possibility that turning off pain could lead to normalcy?
Now this suggestion, while logical, is a huge uphill battle. I cannot remember any aspect of learning how to look for pain free objective signs in PT. My education, both during schooling, and in most of my 574 hours of post-graduate continuing education since has been focused around pain producing special tests.
Problem? Chad Cook and Eric Hedeges would argue yes!
Chad and Eric have authored 2 different documents that are leading our profession to question what we are even looking at with our ‘special tests’. One is Orthopedic Special Tests Volume 2 and the other is an opinion piece published in JOPST earlier this year (2017). The over-simplified conclusion? We have fooled ourselves with biased research and a misunderstanding of previously conducted studies that have yielded and abundance of unreliable special test…that aren’t that special!
So back to my early statements. What kind of value could be place on performing tests that were designed to eliminated symptoms instead of producing them? I have established a habit over the last several years of attempting forms of pain-eliminating tests first to determine results, then returning to the pain-producing testing after to compared notes.
Something interesting that I have found from symptom-eliminating testing is the response from the patient. Case in point, imagine the painful knee patient who has already been told that they have advanced arthritis in their knee and that portions of their meniscus are torn after MRI. Often, they are unsure as to why they are in therapy because their condition cannot change and their beliefs have been established from a consult from a healthcare professional who has not educated them on pain or the research findings that knee OA does not equal pain and dysfunction for every person. If I perform painful special tests on them in an attempt to produce pain or limitations first, I often justify to them their beliefs of the problem or issue. Now, what if I attempt the opposite. What if Mrs. Jones is a responder to improved pain-free ROM and function with simple forces applied across her joint line while she performs that actions that she describes at limiting? “What happened to my OA?” is the most common response I get. “Exactly my point. Nothing happened to your OA Mrs. Jones. But now we know that your body has the capability to operative without that limitation. So now we just have to figure out how to make that change permanent.” Moving toward a complimentary team effort with my patient about what means the most to them and away from fully passive treatments has made it easier to establish patient empowerment and control over their symptoms. People feel listened to. 2) If symptoms can be altered, and preferable abolished, it automatically begins that question of “If I can move without that pain or restriction now, what happened to my “X” (insert OA, tear, degeneration, posture, etc) diagnosis?”. The transition from a diagnosis to Pain Neuro Science (PNE) happens seamlessly. Beginning to understand that the vast majority of symptoms that we see clinically in an outpatient setting fall under the category of “top down”.
Imagine a world where you were above to move and function without pain?!? Yeah…it’s called normal!
It may be easily argued that the Therapeutic Alliance has already begun in this scenario. The patient would likely “buy in” to the treatment approach quickly with a positive response. Especially compared to the more traditional approach of “light switch on” special testing and treatment. But “light switch on” not only does have value proven in the literature (see cross over leg raise example here), but working with pain can have its advantages as well. I often have my clients focus on the pain that they are having and determine what happens to their pain when they move or exercise. “Ok. Let’s see what happens to your pain or limitation if you do more repetitions? Is it getting worse, better, or staying the same the more you do? I classically get even more information after a bout of painful exercise or movements…”now let’s try that again and tell me what has happened to that pain you were reporting earlier.”
Unfortunately, while there have been countless observations in the literature of these types of treatments (see here), to my knowledge there have not been any performed directly related to specific conditions. But do we really need specific research to perform “light switch off” testing? Can we really infer that a sub-group of responders would give any value over an N of 1?
Perhaps we have given the painful approach too much credence over time. Have we relied on special tests and painful treatments to define who we are as a profession? Maybe. Is it time for a paradigm shift in how we conduct an exam and treatment and start including pain-free testing and treatment? Maybe it’s time to consider both pain free manual therapy and pain free exercise. And if we can do that, then LOAD IT! Load it heavy, and often, with current suggestions from Prof. Jill Cook among others.
Thanks for reading. Now that you're done, turn off the light please!