Treatment outcomes are influenced by more than most people think.
To the average person who rings up a clinic, books and appointment and then shows up to get help with their painful problem, the expectation is that the treatment will do something, and hopefully make them feel better.
Often, people do get better, but not because of what they had done treatment wise.
If someone feels better, does this even matter? Is the outcome all that is relevant?
To me it does.
And it should to you as well.
Well, firstly, if you are paying for treatment and getting better despite what was done, not because of it, then you are wasting your money. I don’t know about you, but I work too hard to be wasting my money.
Secondly, if there is risk associated with a particular treatment, and an equally effective alternative is available that has less risk, well it’s obvious you would want the safer option.
Thirdly, if we know what influences treatment outcomes, we can strive to optimise all the variables.
So what are the factors influencing treatment outcomes?
If a practitioner wanted to look really good, they could focus on treating acute low back pain.
Simply seeing people for 12 weeks would give them approximately a 70-80% success rate (condition resolving), no matter what they did! (1) This is because for most people, acute low back pain is a self limiting condition that gets better with time. Experienced practitioners can probably predict your recovery more accurately (and there is research to support this). Essentially, they could just play the numbers and end up looking good. (2)
There are many similar conditions that do get better with time, and what research is showing us, is that often minimal management is just as good as lengthy treatment plans. (3, 4)
On the flip side, there are some conditions which we simply cannot treat, but rather have to settle for managing as well as we can. Many (but not all) chronic pain conditions fall into this category.
Recall how I mentioned many conditions improve with time?
Well if you suffer from one of those, then you need to be patient. This is often lacking. I don’t know if impatience is more prevalent these days compared to decades past, but it definitely makes people do silly things.
Things like taking too much medication, seeking out controversial treatments and “doctor shopping” for stronger analgesics are all too common.
If a practitioner says the best course of action is to do nothing and wait, then they aren’t being lazy, and they are definitely not idiots (as is commonly mentioned to me in practice). What it means, is they are likely trying to save you from unnecessary interventions, which all have potential costs and risks.
There is growing body of research showing that your expectations have a big influence on whether you get better.
This isn’t a case of new-age “believe in it and it will come true” stuff either.
Rather, if you expect a certain outcome, both consciously and unconsciously your behaviours and thoughts end up shaping that outcome.
This has to do with all sorts of things, but I like to credit the concept of priming for some of it. (5)
Priming is when you are shown words, pictures or similar with a certain theme, and then you are unconsciously influenced by them. Studies have used elderly words with students for example, and the students have changed posture and walked more slowly. When young words were used, they moved quicker and stood taller.
Because of this, managing expectations is one of the most important aspects of treating pain. If you are expecting to get better in 2 weeks, but you have a 2 month condition, you will need to adjust your expectations accordingly.
Likewise, if you expect you won’t get better because you are “old” and have lots of “wear and tear”, well chances are, you won’t.
Your Current Health Status
People who are healthier recover from injuries faster.
People who recover well from injuries are less likely to go on to develop chronic pain.
If you have co-morbid conditions you are likely to recover slower than someone your age with the same condition who is healthier.
Some things are in your control: what you eat, how much you move, whether you drink and smoke or take drugs.
Some things aren’t in your control: genetic predisposition, accidents, environmental factors.
All you can do is to try and maximise the positive things you can control, minimise the negative and worry as little as possible about the rest.
Your Socioeconomic Status
This isn’t talked about much, because in Australia (and many other cultures) it is generally taboo to talk about money.
If you are in a low income household, or unemployed (not by choice), then your both your current health status and your recovery from painful problems are negatively affected.
The eminent British epidemiologist Prof Sir Michael Marmot, the president of the World Medical Association and presenter of 2016’s ABC Boyer lectures, has shown that a person’s lifestyle and health choices (what medical types like to call your “risk factors”) simply cannot account for the differences seen in death and disease among people of different incomes. In his landmark Whitehall study, which examined British men working in different levels of the public service, those on the lowest grade of employment still had double the risk of dying from heart disease – even when accounting for all the factors we traditionally think of as causes. There was a clear gradient of risk between levels, with deaths decreasing as the public servants climbed the employment ladder. (6)
Being an osteopath, I’m not trying to solve all our political and social issues, but they must be considered when considering outcomes.
This is a topic that interests me to no end. Two great questions linger in my mind:
- How much of somebody’s outcome is down to practitioner skill?
- What components of practitioner skill are the influential ones?
If you look at all the other factors, you can see pretty quickly that practitioners often take more credit than they deserve for achieving positive outcomes, then turn around and blame every other factor but themselves when they don’t.
I feel that the skill of a practitioner is not only having good diagnostic and treatment skills, but being able to have all these listed factors circulating in their minds simultaneously, while also giving people the voice, space and time they need to explain their story.
They then need to put all this information together into a plan of action that people can understand and apply, so that they actually achieve the desired outcomes.
I think that selecting a good practitioner can actually be the difference between developing chronic pain or not. There is evidence to suggest appropriate identification of risk factors, coupled with education and reassurance all reduce the likelihood pain progresses from acute to chronic.
So what makes a skilled practitioner?
I would say they all have highly developed the following attributes:
- Clinical knowledge
- Clinical reasoning
- Clinical skills
- Assessment and diagnostic skills
- Treatment skills
- Rehabilitation skills
- Communication skills
Each of these areas is a massive topic, which means it takes time to develop them.
This doesn’t mean that more experienced = more skilled. Rather, it means you need to be continually learning and applying, so that your experience is congruent with the current scientific understanding.
All this complexity is why they call it practice.
The purpose of this post was to illuminate the complex nature of treating pain and injury, and why things don’t always go to plan.
This is why it is important to have the right support. Family and friends are a good starting point, as they can provide social support and reassurance, but for anything more than a simple strain, often it is good to have medical management, to (hopefully) prevent the slide from acute to chronic.
Good education from the beginning, appropriate management (not over management, not under management) and a view to long term outcomes, not just symptom relief are all signs you are in the right hands.
It’s always funny to me that someone will happily drive half way across the city to go shopping, but when it comes to health professionals, many people choose convenience.
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.