Can we please stop pathologising! What does that mean? Well I am pointing the finger at you the clinician. This includes me! There are plenty of us out there who are guilty of pathologising and creating a society of hypervigilance.
It’s a growing concern of mine that we continue to see trends of pathologising. I continue to see unhelpful information coming out about activities that we perform on a daily basis. A perfect example of this is the text neck nonsense.
I read that story and thought to myself how many times a day do I look down, so I decided to compile a short list.
- I look down when I go to get up from lying in bed
- I look down when I stand over the toilet to make sure I don’t miss the bowl
- I look down when I put my clothes on in the morning
- I look down when I’m making and eating my breakfast
- I look down when I put my shoes on
- I look down when I pat the dog or cat
- I look down when I’m treating my patients
- I look down when I’m reading a book, paper or journal
- I look down when I’m writing a blog post
- I look down when I’m vacuuming. cleaning, doing other household chores.
Ah but (I hear you all cry) the counter-argument is that the prolonged length of time that we are texting places extra strain on the neck. I would agree but that also highlights that it is not about texting it is about the prolonged time that we are looking down, the sedentary posture, but perhaps its more than just the mechanical effects, that healthcare professionals appear to be so transfixed on.
There are many other examples of overloading, what about the accountant that sits too much, builders that repeatedly lift too much, runners that run too much, rowers that row too much, hikers that hike too much? Hopefully you can see a picture unfold here regarding hypervigilance. What’s my advice for this? Well depending on your level of resilience, think about what you can do to avoid these prolonged activities. Break them up a bit throughout the day.
There are so many messages from clinicians, the media, social media and other mediums regarding what we should be careful of, and that there will be severe repercussions if we aren’t. We are becoming a hypervigilant society. We are surrounded by things that are consistently labelled as bad for us, such as the pictures of the text neck story that polluted our media and social media last year. Fortunately we were not fooled and very quickly an alternative picture surfaced.
More recently another picture has surfaced highlighting the orthopaedic perfect storm of sitting. This picture is directed at students and the younger generation. There are some classic words in there such as ‘douchebag’ shoulder and ‘kankles’ – way to go at affecting a kids self-esteem…..
As if children aren’t stressed enough at school, learning different subjects, studying for exams, having to deal with bullying, going through puberty, pressure from peers and family to do well in all aspects of education and sport. Do we want to increase their stress more by telling them what could go wrong if they sit for too long? Sitting is just as bad for you as running would be if you didn’t rest. What next, are we going to start telling children not to participate in sport because of all the possible injuries they could be exposed to? What I find even more frustrating is that there are very few solutions to these so-called bad habits.
Why do we have to live in a society where everything is scrutinised as a bad habit. I recall having a conversation with a podiatrist about a seminar she had attended at a post-graduate lecture on incorrect lifting technique. You can read the article here. I don’t dispute that the forces are different between the two styles of lifting shown and that one causes less stress on the back. Yet does that really matter? If the task in front of the individual is perceived as a threat then it doesn’t matter how the item is lifted, the persistent back pain sufferer who has not lifted a box in years is unlikely to lift it.
A further example of poor communication and education I experienced recently was during an assessment of a hockey player. The player (now 20 years old) had a long history of shin pain (compartment syndrome) and last year had received his second bilateral fasciotomy of the posterior compartment*. The evidence for posterior decompression is weak and a recent paper has also highlighted a high level of interobserver variability in measurement of compartment pressures (reference, reference, reference).
Further questioning revealed that the player was informed that he lost around 50% of his calf muscle mass and he was told that he should not perform calf raises post surgically for 18 months. Paradoxically, he was told he could resume playing hockey after 8 months. Now either I’m really stupid or I’m completely missing something, but that just doesn’t make any sense to me. What this highlights is how we need to be so clear with our explanations and our education towards patients. The player continues to suffer with pain and his physiotherapy to date has now focussed on maintenance (acupuncture and massage).
I have highlighted before in a previous blog (here) that we have to be careful with our communication. There are many instances where we may think we are helping, but when our language, instructions, and advice are taken very literally it can result in mis-interpretation, and ultimately becomes a hindrance to recovery. As @jevnehelse recently posted up on twitter, we really do need to stop making our patients worse.
So how about some helpful posters…. The New Zealand Neurological Society have released a really helpful poster that encompasses several lifestyle aspects that support a healthy brain. If you maintain a healthy brain you reciprocally maintain a healthy body!
Louis Gifford was very much an evangelist in his clinical work and in writing his Topical Issues in Pain series of books. In that he wrote an excellent piece about pink flags. Louis explained that clinicians were very good at highlighting the bad such as pathology, yet not so good at informing people of how we heal and recover, unable to give timeframes. I feel that we are still very bad at this, somewhat hesitant of getting something wrong. So in order to help and for a bit of fun I have created green flags to facilitate our understanding of how we can wave the ‘green flag’ to encourage patients to get going again.
Clinicians require more support in being able to empower the public and our patients on the journey to recovery. It’s important that we are honest and realistic when educating our patients on this journey. Nothing is ever plain sailing, there will always be speed bumps along the way, but we can help by providing less of a focus on pathology and more of a focus on empowering patients to facilitate their journey to recovery.
So let’s start focussing more on empowering patients and being mindful of our communication. As all it takes is one mis-interpreted biomedical reference to create a snowball effect towards a cascade of chronicity (louw & Puentedura, 2013).
Thanks all for having a read and as always your comments are welcome.
* A common surgery for compartment syndrome is a fasciotomy or decompression, where it is understood that a surgical procedure releases the pressure in the leg resulting in an alleviation of pain.