The Bigger Picture

big picture

In the foreword for Pain: A Textbook for Therapists, Patrick Wall writes

I am convinced that physiotherapy and occupational therapy are sleeping giants [in the treatment of pain].

Wall saw persistent pain and disability as a giant problem that required a giant solution. He could not have been more right. In the United States, pain and disability’s total financial cost ranges between 560 and 635 billion dollars. Despite the public awareness for things like heart disease, cancer, and diabetes, total financial costs for pain and disability nearly exceed all three combined. For context, heart disease costs 309 billion annually, cancer comes in at 243 billion and diabetes is about 188 billion. A large portion of the cost of pain and disability comes in the form of hours and days of work missed as well as the medical costs. As the burden of pain and disability continues to grow, so does the body of literature showcasing our profession’s ability to provide a safe, low cost and effective healthcare provider for those in pain.

We now have trials demonstrating that physical therapy can significantly reduce low back pain related healthcare costs, is effective in treating atraumatic full thickness rotator cuff tears, can reduce the need for surgery in knee meniscal tears and osteoarthritis, and much more. Such trials are profound and absolutely should impact the global delivery of healthcare. The cost effectiveness and risk profile of physical therapy compared to polypharmacy and surgery is compelling. There is encouraging data that early and intense physical therapy in the acute and intensive care unit settings can reduce days on mechanical ventilation, length of stay and iatrogenic complications (see here and here for some primers on this). This information is powerful and we should leverage it to affirm our role within the bigger picture of health care. We should be united as a profession by our ability to make a positive impact on society through “optimizing movement to improve the human experience”

However, to solidify our position in the bigger picture of healthcare, we need to be constantly refining our smaller picture. That is, we need to foster a culture of rigorous debate, critical thinking and agreeing to disagree within our profession. This is unambiguously necessary.

Recently, I have observed numerous discussions in social media where it was suggested that debating semantics, effectiveness (or lack thereof) of interventions and the validity of a treatment’s premise is unhelpful and potentially damaging to our bigger picture. While it is true that in the global context of healthcare physical therapy interventions carry little acute risk and are likely a better first choice. But is that the whole picture? I doubt it. Many patients under the care of a physical therapist have gone on to seek more medication, more surgery and more injections because conservative care did not meet their needs. To address this, we must be asking “why?” and digging deep into the strengths and weaknesses of our profession. We have to constantly critique, create, prune, and debate aspects of our care.

I would argue that debates on premise and effectiveness are essential to the evolution of our profession and when they are done correctly serve only to strengthen it. Critique and argument drive progress in all scientific disciplines. What we should do is challenge ourselves and our colleagues to think critically about our interventions and processes with an awareness of the big picture. Digging into the minutiae of our profession fosters a constant refining of our practice. Discussing interventions in regards to their scientific merits gives us a clearer image of their benefits and limitations. This clarification of the small picture will allow us to better impact the big picture of health care.

What we shouldn’t do is use this big picture context as the primary justification for interventions, approaches, or schools of thought.

“Well, it at least it’s not surgery.”
“It’s safer than drugs!”
“It’s cheaper than an MRI”
“We have a pain epidemic”

…while true, important, and sadly profound statements, these in isolation are flimsy primary arguments for interventions that are unsubstantiated by science. This is how many proponents of complementary and alternative medicine justify their interventions and existence. We as a profession cannot expect to chip away at the harm of unnecessary surgery and polypharmacy if we are not able to hold ourselves to the same standard when appraising our own care. We should pay just as much attention to trials that illustrate our own ineffectiveness as we do trials that highlight the shortcomings of surgery for painful problems. I am not sure if we currently do that as a profession. If we continue to accept poorly supported interventions and approaches to care simply because they are less bad, we run the risk of marginalizing ourselves. Semantics are important and as Maitland said “To speak or write in wrong terms means to think in wrong terms.” Semantics matter in research, they matter in clinical practice, they matter in education, and they matter in patient care. It may sound like minutia, some of it may even be minutia, but accountability in the refining our small picture is needed.

The context of healthcare at large should be used to showcase WHY certain populations and conditions are best managed conservatively by a physical therapist as opposed to other riskier or more invasive options. We should continue to demonstrate our value in healthcare through thoughtful research and development of rational and novel interventions. For a specific example, Adriaan Louw and others recently have shown that preoperative neuroscience education can decrease overall healthcare costs and utilization in patients with lumbar radiculopathy. This is compelling example of how a carefully refined small picture can make an important impact on the big picture.

It is faint praise to be considered the best option for painful problems simply because the alternative is so poor. It is easy to argue that physical therapists are the best option for painful problems because the alternatives are so expensive, risky, and grossly ineffective. The fact remains that if we are not providing effective conservative care, we are actively contributing to the growing burden of pain. We must assert ourselves as the best option for those suffering from pain and disability based off of our own merits as a science based profession. Through debate, argument, research and a constant refining of the smaller picture, we will continue to improve in our ability to serve an important role in the bigger picture of health care. Minimizing the importance of the smaller picture (consciously or otherwise) risks degrading our professional reputation.

Physical therapy’s dedication to being an evidence based profession is what will allow us to reach the potential that Dr. Wall wrote of. We should continue to debate the minutiae of our clinical practice and our research. We should continue to define our value as a health care provider in the context of healthcare as a whole. What we can not do is become myopic and lose sight of one or the other. In order to wake up, we need to be able to see both the big and the small pictures.

Photo courtesy of flickr user brongaeh

5 thoughts on “The Bigger Picture

  1. Are you aware that this article with a quote claiming occupational therapy is a sleeping giant in the field of pain, then go on to speak about physical therapy? A typo or did I miss that section of the article. Lol! I recommend articles in AJOT that account to occupational therapy intervention helping paitients who experience of chronic pain.

    • Hahaha, well played D’Andre. Occupational Therapy is an excellent field and I’ve had the good fortune of working and learning from some truly fantastic OTs. If you can recommend any articles in particular, I’d love to check them out

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