You can’t cut out pain. – every *good* orthopaedic surgeon ever
Despite what we know about pain, many people are subjected to poor medical management for their pain on a daily basis.
From the recommendations of medications that don’t work for certain conditions (ahem, anti-inflammatory drugs and low back pain), to expensive courses of passive therapies that have extremely low effect sizes.
Not only do these treatments not work very well, they are is an enormous waste of everyone’s resources. To make matters worse, many of these management strategies are not benign, meaning they have the potential for negative side effects.
When it comes to poor medical management, over the counter medications and ineffective passive therapies are the (very small) tip of the iceberg. Many costly, and potentially dangerous drugs, invasive therapies like injections, nerve blocks and the “grand-daddy” of them all, surgery all carry high risk profiles and for very small benefit, especially over the long term.
It’s right about now that I should add some moderation to this post:
I’m not saying these treatments are completely worthless all the time. In fact, I have had many patients who have benefited from the right prescription or surgery over the years.
What I’m saying, is that these treatments often come with big costs and risks that are not fully disclosed when they are recommended (although nearly every surgeon does a better job at explaining the risks of their treatments to patients, many still overplay the benefits or don’t fully explain the alternatives).
With this in mind, the sleeping giant in the treatment of most painful problems, especially those involving the musculoskeletal system is good conservative health care.
I emphasise the good, because there is so much bad out there.
No, I’m not trying to be negative and put down other health professionals. I am simply stating, that based on my experiences with patients (and supported by research), many have not had adequate conservative care to begin with, which is how they’ve ended up with chronic conditions in the first place.
What Is Conservative Health Care?
Conservative health care is based around interventions designed to avoid radical medical therapeutic measures or operative procedures.
They are typically lower in cost than more aggressive treatments, which a much safer risk profile.
The downside is that some conservative treatments don’t have a large effect size, and many work in general, not specific ways.
Some examples of conservative health care include:
- Education, advice and reassurance
- Lifestyle changes
- Dietary changes, including supplementation
- Exercise based interventions
- Physical/manual therapy
- Certain medications
When Should You Seek Out Conservative Health Care?
Conservative health care is not appropriate for all health problems.
Serious and life threatening conditions typically need more aggressive and/or invasive treatments. Examples of such conditions include major infections, cancer, organ diseases and major trauma (though there are many more).
When conservative health care is most optimal, is when a condition is chronic and stable, or progresses slowly, when the condition is self-limiting (i.e. it will resolve with time, and symptomatic management is all that is required) and when the condition is non-specific (it can’t be attributed to a single cause), like many low back pain presentations.
Usually, a general practitioner will be able to advise you when conservative options are suitable, so that’s often a good place to start.
Conservative Treatment For Pain
Pain is the number one reason people consult their GPs, however, a lot of pain is very poorly managed from the begining, leading to the progression towards chronic and more debilitating pain.
This is where I feel that conservative management can really shine.
Almost every chronic condition will improve to some degree from improving your health generally.
Additionally, many chronic pain presentations will benefit just as much, if not more in the long run, from good conservative management.
Unfortunately, many people miss out on receiving good conservative care when they need it most, leading to them needing/wanting more aggressive treatment options when their condition has progressed.
The Benefits of Conservative Health Care
Conservative health care has a number of benefits for all parties involved: patients, practitioners and 3rd party payers (insurance companies, governments etc).
One of the biggest benefits is economic.
Let’s take chronic low back pain as an example, because it is so prevalent, and so widely researched.
The cost of these conditions to the Australian economy in 2012 was more than $A55 billion. Back pain and osteoarthritis, the most common of musculoskeletal conditions, accounted for 52% and 41% of cost respectively.
When we look at the costs, most people intuitively think of the cost of treatment (consultations, investigations like imaging, medication etc), however, the bigger cost is the indriect cost, that is the cost to society and the individual of lost income, productivity and quality of life as a result of their condition.
While the direct costs of chronic conditions is around A$9 billion annually, the indirect costs are a staggering A$54 billion annually!
With such high costs, you’d think that prioritising excellent conservative care from the outset would be high on the agenda for all involved.
Unfortunately, many clinicians do not follow the clinical care guidelines which are developed by compiling the best evidence from researchers around the world. In fact, only 20% of low back pain patients received care inline with the guidelines.
These guidelines are designed to ensure the best possible management of each condition, yet with only one in five people getting treatment based around them, many are missing out and going on to develop chronic pain, which ends up costing them in time, money and quality of life.
Other benefits of conservative health care include:
- Safety – by definition, most conservative health care is low risk.
- Availability – there are typically many more health professionals able to deliver conservative health care than specialists who deliver more invasive treatments.
- Sustainability – conservative approaches can typically be maintained over the long term, which can help manage chronic conditions.
What stops people getting good conservative treatment?
I believe that most of the time, most people are doing the best they can. As a result, the lack of implementation of clinical guidelines for conservative care is not down to any one factor, but here are a few:
- Market forces – funding for public health services is always stretched, so GPs cannot spend adequate time educating patients. Private practice clinicians are often limited in the number of times they can see someone due to a patient’s ability to afford treatment.
- Expectations – patients often want to be “fixed”, not understanding, or wanting to participate in more active management for their conditions.
- Practitioner knowledge and skill – most health practitioners are skilled in diagnosis and treatment, not in facilitating behavioural change. This makes it hard to create long term, empowered change.
With this in mind, we can see the challenges that need to be overcome to offer the best available conservative care.
What is needed to improve conservative treatment?
- Government and insurance companies need to appreciate the long term cost savings conservative care offers, and fund it accordingly. If a surgery costs $20,000 spread across direct and indirect costs, and that surgery could have been prevented by 2 years of physical/exercise therapy, then even at $100 per session, twice per week, you are coming out at break even. However once you add in the rehabilitation costs of surgery, and the costs of the increased risk, the physical therapy option is actually cheaper.
- Patients need to take responsibility for their thoughts and actions. Yes, circumstances can affect everyone, which can make life harder and less fair for some, however, taking 100% responsibility for how you respond and act will mean that you are in the best frame of mind to improve your situation and your condition.
- Educational institutions need to adapt to the changing demands on healthcare and focus more on communication and behaviour change. Simply increasing the awareness of this important skill will lead to those interested healthcare practitioners pursuing further education.
- Health practitioners must accept that they can always improve, and seek out ways to develop their skills to better serve their patients. This includes seeking out appropriate continuing education, but it also means enhancing their networks and their ability to utilise these networks to benefit their patients.
The Big Two
Of all these factors, the two most important are economic and cultural forces.
Money is always an influence on how we make decisions, and many people simply don’t have the financial freedom required to pursue optimal conservative care, especially privately.
While there are always those who are living on the edge, and literally have no room in their household budgets for anything about the essentials of living (housing, food, transport and utilities), there are many more who claim that health care is too expensive. Yet these people walk around with the latest iPhone on a high monthly plan, or drink/smoke/gamble regularly. For these people, who may be on average incomes, it is simply a matter of choice and priorities*.
This is where culture becomes important.
Our culture in Australian is heavily influenced by commercial interests.
Unfortunately, there is a lot of money to be made in selling treatments for conditions that offer a simple solution to a person’s health problem.
Whilst they appeal to our emotions, simple solutions are usually inadequate for complex problems.
So when you propose a long term course of conservative care, which involves active participation by patients, it is often a tough sell.
It is made even tougher by the massive marketing budgets pharmaceutical companies and medical device companies have. They use these to influence our culture. Every night on TV there are commercials for different types of pain medications. Ironically, if most people spent just 30 minutes less watching TV, and decided to go for a walk instead, they probably wouldn’t need them anywhere near as much.
A Different Perspective
If instead of thinking in terms of expense (cost and time/energy), you changed focus to investment, then immediately you have changed your perspective on health.
When you invest in a term deposit, at the end of the term you have more money than when you started.
Conservative health care, done properly, is an investment.
Yes, you are spending time, money and energy to change your health, which has an initial up front cost. But, by the end of the treatment program, you should have improved health, reduced pain, better function and an overall better quality of life.
Get more years out of your life, and get more life out of your years.
These improvements can be thought of as your return on investment. Like a term deposit, conservative treatment is mostly safe, offers fairly predictable outcomes and is overall, low risk.
Once you have restored your health, the idea is to maintain it (just like you would with wealth). Usually this means you need to continue your healthy habits which you established during treatment.
A final word on perspective; if you are in debt, you must pay back your debt before you can invest. The bigger your debt, the more work and time it takes to repay. The same school of thought applies to health. While things can change quickly, true healing from chronic conditions, or even severe acute conditions, takes time.
If that puts you off, think about it like this: time will pass, regardless of what you do or don’t do. If you do nothing, you will be in the same, if not worse situation in a year or ten.
Conservative care is extremely important from both a public health and individual perspective. Delivered optimally, it saves money, improves outcomes and reduces the need for interventions with higher side effect or risk profiles.
There are some barriers to delivering good conservative health care at the population level. On an individual level, the two most important variables can usually be overcome.
If you are a patient: when you are seeking out a health care provider, discuss long term strategies and look for providers who will incorporate an active management plan.
If you are a practitioner, you should look to improve your communication and behavioural change skills. Telling someone what to do isn’t good healthcare. Guiding them through the process of how to do it is.
This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.
This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.
*For those who are truly struggling, most universities with allied health programs have student teaching clinics. These allow students to provide supervised care at reduced costs. In special circumstances, the fees can even be waived. Bottom line, no matter your circumstances, if you are really set on helping yourself, you can find a way.