Creating and capitalising on vulnerability is not healthcare
It’s that time of year again when the marketing campaigns ramp up to ensure therapy practices don’t go out of business over the holiday season. One of the most common strategies I’ve seen emerge over the past few years is the ‘Get your free spine check now’ campaigns.
Look, I am well aware of the dichotomy of healthcare and business that health practices are trying to navigate, but to create vulnerability in people to capitalise upon is a) not indicated, b) has potential for harm and, c) is unethical and down-right must stop. This is a great example of when screening does not assist the burden of an issue but may potentially increase it.
Here are just a few reasons to why no one needs to have their spine checked and what to do instead.
90-95% of back pain is non-specific in nature. This does not mean it is not specific to the individual, but what this really means is that we are unable to discern a specific anatomical structure or reason for the individual’s pain. The majority of our special orthopaedic tests have a high sensitivity and a low specificity. This means if you have back pain we may be able to rule out some pathology, but it does not allow a clear diagnosis (REF)(REF). There is no efficacy in assessing individuals without symptoms.
Imaging is not indicated even when someone presents with back pain (with no red flags). Imaging to find abnormalities in someone without pain is even more controversial with it now being well established that many findings are found in asymptomatic populations (REF). Further research has also established that those who have early imaging gain no benefit and may have a worse prognosis (REF). Prescribing exercise to try and correct any of these findings is unlikely to have any efficacy. Specific manual therapy treatments also lack efficacy in addressing these findings and are considered to have non-specific effects (not unique to any other treatments that promote neurophysiological responses) (REF) with manipulation being no better than sham (REF). Any changes in symptoms are more likely due to neurophysiological responses like placebo, regression to the mean, and time.
Movement screening seemed plausible. If people were stacked in better alignment and moved with a more mechanical/linear strategy we may reduce joint forces and wear and tear… The literature doesn’t support this notion. Movement screening has been shown to be little better than flipping a coin for predicting injury (REF)(REF), with other studies also suggesting scoring higher may increase your likelihood of injury (REF) – either way, we aren’t seeing a strong relationship with using movement screening as a predictive tool.
Posture has had a variety of importance over history; from military training and unified mobilisation of troops, to an indicator of societal class. It wasn’t until the 20th century that we started to postulate a relationship between posture, pain and future injury. Despite considerable efforts to draw correlation, the evidence to support a strong relationship is weak at best (REF)(REF)(REF). Posture screening at this point in time is nothing but an activity with high nocebic risk. Pathologising someone’s unique posture is not an acceptable behaviour in healthcare.
Assessing the core. Strength of the core – or timing of the core – any definition you would like to use is not strongly related to back pain. In fact, the early work of Hodges and Richardson (REF)(REF) have been so highly researched now that 6 out of 7 systematic reviews have now shown no benefit in prescribing motor control/TvA based exercises over that of just general graded exercise (REF)(REF)(REF)(REF)(REF), with one stating motor control exercises had better outcomes but, “It is to date not known if the effect of MCE (motor control exercises) on pain and physical impairment in LBP is due to the isolated activation of the local musculature or subsequent stages of the intervention involving loaded postures engaging all trunk muscles.” (REF) One other systematic review concluded, “There is strong evidence stabilisation exercises are not more effective than any other form of active exercise in the long term… further research is unlikely to considerably alter this conclusion.” (REF) You don’t get much more conclusive than that in academic writing.
The assessment of glutes is also inherently flawed. People with back pain have been shown to, at times, have increased activity of their gluteals than their asymptomatic counterparts (REF) and are more likely to experience pain with more muscle activity (REF). The Trendelenberg test, an assessment for gluteus medius weakness, also falls short after a study in which it was inhibited via an intramuscular injection (52% reduction in EMG activity) and the Trendelenberg assessment did not change (REF). Not to say doing exercises to work these muscles aren’t fine to do, but to denigrate them as a causative factor for someone’s pain may not only be unevidenced, it may also create unnecessary negative beliefs and may just bore the shit out of your patient with clams and glute bridges. In line with this blog, to screen glute activity for people without pain, needless to say, we can find better things to focus our time on.
There is no such thing as a bad exercise. We should be promoting movement and getting people active, and the best way to do that is to get them doing what they want to be doing, not rolling around on the floor trying to engage some hidden muscle that has been hidden for centuries, or trying to break up some fascial tissue that still is contentious at best to whether it is modifiable from the relatively small amounts of force we can exert from our manual therapy strategies/foam rolling (REF). At this stage, there is insufficient evidence to suggest this be a target for specific, preventative measures beyond that of just moving. We understand that comorbid conditions and mental health do have a relationship to pain, and it should be in our best interest to support individuals to increase energy expenditure and self-efficacy with every opportunity we can (REF)(REF)(REF).
We should be encouraging the idea that back pain is a normal human experience. In most cases, it will settle by itself, despite it being very unpleasant, and we need to promote the notion to keep moving and work within their tolerance. Understanding key concepts like pain does not equal damage and to work within their tolerances may need to be considered to promote greater self-efficacy. Reassurance is in the guidelines (REF)(REF) for all musculoskeletal pain, acute and chronic, and despite that sounding overly simplistic, it may be one of the hardest skills to execute. It requires empathy, thoroughness, a strong therapeutic alliance, and education that is patient-centred.
It could be argued that healthcare seeking behaviour in itself is a yellow flag, meaning that the fact they are in your practice suggests they already have questions to whether their body has the capacity to heal and adapt without intervention. To promote seeking healthcare advice, like in these marketing promotions, without any issues, is only perpetuating the problem. Instead, promoting the incredible healing capacity of the body may be a far more effective strategy in combating this epidemic.
As always, I hope this causes some cognitive dissonance and some productive discussion. One or more of these strategies may really bother you, but before you get defensive, consider whether the assessment you use puts the patient in the driver’s seat, creates more self-efficacy and promotes positive beliefs about their body – we know these factors are key in optimal outcomes and promoting positive health behaviour. I’m always open to the counter arguments, however, if the argument further risks us being distracted from treating the person sitting in front of us, then it would have to be incredibly persuasive!
There is much we don’t know about pain and injury however creating vulnerabilities to create a more successful business is NOT healthcare.
Brendan Mouatt is an Accredited Exercise Physiologist and Director at The Biomechanics Clinical Practice in Melbourne, an educator and director at The Knowledge Exchange and a researcher at The Body in Mind Research Group at UniSA in Adelaide, Australia.