Why You Should Choose Conservative Health Care

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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?

  1. 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.
  2. 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.
  3. 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.
  4. 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.

Conclusions

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.

 

Nick Efthimiou Osteopath

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.

 

 



 

 

 

Notes

*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.

References

(1) Medibank: Chronic pain costs economy more than $22bn a year

(2) Pain drain: the economic and social costs of chronic pain

(3) The burden of musculoskeletal conditions in Australia: a detailed analysis of the Australian Burden of Disease Study 2011

Tightness Is A Stress Response: Get Regular Treatment To Reduce It

Visceral manipulation.

Most people think tightness is a muscle problem.

In actual fact, tightness is a stress problem.

The key to managing stress is not to eliminate it completely.

Instead, aim to reduce what you can, and better respond to what you can’t.

[Let’s get this out of the way: tightness is not a scientific or physiological term. But we all know what someone means when they say it. In physiology we talk about shortness, stiffness and muscle tone.]

We Are Like An Oil Burner

I have heard world renowned strength coach Charles Poliquin describe us as an oil burner.

Our output is the flame, which can only be as big as the oil reserve allows.

Everything we do, both positive and negative, burns some oil, to keep the flame going.

If you are like most people, you are over stressed, under slept and nutrient deficient.

You have ever increasing work demands. You want to spend as much quality time with your family as possible. You do try and get to the gym or go for a run, but some weeks you simply can’t make it.

That’s a lot of burning, and not much refilling.

Add all this together, and your brain puts you in fight or flight mode.

Now if someone was about to hit you, would you be tense or relaxed?

Well to your brain, stress is stress. Whether it is a fight, a work deadline or your kid getting sick.

Tightness Protects Us Against Stress In The Short Term

You can see that an increased muscle tone is the result of stress, but can you see the benefit?

A muscle, or joint that is tight is protective against stress, in the short term.

That increased stiffness helps to resistance against external disturbance.

But this protective behaviour comes at a cost: it impairs function.

Tight tissues use more energy, don’t drain properly and can’t contract efficiently. (1)

We aren’t designed for sustained bouts of stress. So when this stress isn’t alleviated, the effects become noticeable.

Be Proactive, Not Reactive

Most people think of going to see an osteopath when they are in pain.

This is like deciding to eat healthy after you’ve had a heart attack. It’s better than nothing, but optimal would have been to eat well all along.

Now, I’m not saying that getting regular treatments will prevent pain and injury.

I’m not even saying that eating well prevents heart attacks.

These are complex events, with lots of factors, seen and unseen that contribute.

That doesn’t mean do nothing.

You can learn to tune into your body, and learn to understand your response to stress.

I don’t recommend thinking about your health from a reactive point of view.

You can learn to get in tune with your body and take the measures to manage stress, in all its forms.

When it comes to getting a treatment, exercise and most things health, being proactive is almost always superior to being reactive.

Use A Systematic Approach To Assess and Measure Changes

A treatment should make you better. That is obvious.

But how do we know?

Anyone can identify areas of tightness and then rub a little and call it a treatment.

To me, a good osteopathic treatment is about working out why.

A systematic approach to assessment takes away the guesswork.

You can then apply the interventions where it is most needed.

This enhances efficiency, giving you the biggest response in the shortest time.

It also allows you to reassess, to measure change.

After all, “what gets measured, gets managed”. More on that next.

Oh, And It Doesn’t Need To Hurt

Remember when I said tightness is a stress response?

That means that you don’t always need deep tissue work that is painful to relieve it.

There are many gentle techniques that do just as a good a job, without the pain.

After all, does it make sense to relieve stress with more stress in the form of an intensive treatment?

There is definitely a time and a place for deep work, but don’t think that because something doesn’t hurt it is ineffective.

How Do You Know How Often?

I have never been a fan of routine “maintenance” treatments.

First, an osteopath doesn’t maintain you.

Second, how often you need treatment should be based on your physiology, not the calendar.

So what you need is a way to keep score. A way to interpret your physiology.

The Old School Way: Wellness Monitoring

Wellness monitoring is an effective way to keep track of your physical and mental state.

Used by sporting teams as a way to monitor their athletes, it is a great way for non-athletes to keep on top of their stress levels.

Wellness monitoring records how you feel and what you did on a day to day basis, given you a score.

This score then indicates when you are over stressed/under recovered.

You can start to correlate this to how tight you feel.

I have linked to a good example of wellness monitoring in the references.

The New School Way: HRV Apps

I’ve talked about Heart Rate Variability (HRV) before, but it’s worth mentioning again.

HRV is a measure of your physiological state.

Lower HRV indicates higher stress levels.

The leading app on the market, HRV4Training allows you to use your phone’s camera to record your HRV. This is much more convenient than using a chest strap every morning. Unfortunately, until now, it has only been available on iPhone. The good news is, in the next week it will launch on the Google Play store.

I will be purchasing it.

By tracking HRV, you can not only see your physiological state, but the effects of your lifestyle.

You can then use this info, correlated to your muscle tone to decide how often to get a treatment.

And of course, you can then use the info to see the effects of treatment.

Or, You can go by feel

At the end of the day, only you know how you feel. If you are feeling tight and stiff, then it’s a good time to get a treatment.

Do you need to be in pain?

No.

We are aiming to be proactive, remember?

This means understanding your body, and intervening before the onset of pain or injury.

The old cliche rings true: “An ounce of prevention is worth a pound of cure”.

 

Nick Efthimiou Osteopath

 

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.

 

 


 

 

References

(1) Will add reference tomorrow, the book is at work

(2)Why Do Muscles Feel Tight

(3) Wellness Monitoring

How Your Mindset Impacts Your Pain

Mind

Most people think pain is a physical problem, because we feel it in our body.

Whilst this is not wrong, it is not completely right either.

This is because all pain has 3 components:

  1. “Bio” (biological – aka what is going on in the body)
  2. “Psycho” (psychological – what’s going on in the mind)
  3. “Social” (what’s going on in our environment)

You might be thinking, that doesn’t apply to me, “I strained my back shifting the couch, there’s nothing going on in my head or around me”.

That might be so, but, even if we strain out back moving furniture (an obvious physical cause to pain), by the time we experience pain, our brains have done a magnificent job of filtering the sensory information from our body via all our existing biases and preconceptions (“psycho” and “social”).

This simply means, if you’ve heard your grandfather complain about how getting old sucks because his back hurts, and if you’ve heard people talk about “wear and tear” or anything else about back pain, you brain, cool as it is, will consider this when deciding whether to produce pain that you feel “in your back”.

The fancy name to describe this, is a neurotag.

I like to think of it as a filing system in our brains.

When you see, hear, or read something about low back pain for instance, it goes in your “file” titled “low back pain”.

It doesn’t stop there. Neurotags, I mean, the filing cabinet in our brain, also cross reference.

So when your grandfather complains about being old and having low back pain, your brain files “low back pain” into the “old” file, and “old” into the “low back pain file”.

So, when you strain your back, causing the sensory nerves to start firing rapidly and bombard the spinal cord with messages of danger, your brain is pulling up all these files:

  • Danger is coming from the body
  • The danger seems to be around the low back
  • Low back pain
  • Old
  • Wear and tear
  • Can’t move
  • Never be the same

Or whatever else is stored in there. As you can imagine, over time, this could get pretty full.

All this means that even a “simple” low back strain is not so simple.

Some people are at a high risk of developing chronic pain, even from a relatively benign back strain. All because of the psycho-social factors involved. This is why it is important to always address all factors involved in your pain. After all, all chronic pain was acute at some stage. 

When it comes to treating pain, your mindset matters.

In general, there are two types mindsets that we can possess.  One can lead to a better recovery, while the other can actually impair your recovery.

The Two Types of Mindset

When it comes to our mindset, we either have a fixed mindset, or a growth mindset.

This concept was first described by a psychologist, Carol Dweck, who once had a teacher who arranged the seating order of the class by IQ. Whilst Dweck was actually in the number one position, she felt enormous pressure to maintain that position, whilst those lower in the order became resigned to their fate.

This teacher inspired Carol to conduct her own research, which lead her to conclude:

People with fixed mindsets believe that they were born with all the intelligence and talent they will ever have, and that this cannot change.

People with growth mindsets, as you might guess, believe that their abilities can expand and improve over time.

The vast majority of people who have had success in life, especially those who have had to overcome adversity, display characteristics of a growth mindset.

How Your Mindset Affects Pain

If you search for articles on “fixed vs growth mindset”, most of the results will be about personal development and business, but this concept can also apply to pain.

The easiest way to demonstrate this is with an example.

Let’s imagine two completely fictitious people, Danny and Danielle.

Danny

Danny, 30, is a rising star in the corporate world. He works his ass off every day to improve at his job – networking, learning persuasion and sales techniques, studying his field so he is on top of his game. He goes to the gym 5 times per week and ensures he eats well most of the time so he looks and feels good. On top of this, Danny has a daily ritual of visualising his success.

One day Danny starts to experience neck and shoulder pain. The onset wasn’t caused by anything in particular, but he did recall training extra hard that month.

Not wanting the pain to interrupt his life more than necessary, Danny seeks the help of an osteopath named Nick.

His osteopath formulates a treatment plan designed to get him back to full training in 4 weeks. In the mean time, Danny reads some articles Nick sent him and does some extra research on the topic from some trusted health sites he frequents.

At 4 weeks, Danny is not only pain free, but he has learnt about injury management and knows how to improve his gym workouts so that the issue doesn’t recur. In essence, he has come back stronger than ever.

Danielle

Now, let’s have a look at Danielle, 35, who is a public servant. Danielle enjoys her life – she works from Monday to Friday and enjoys exploring galleries and cafes on the weekends with her partner. At work she does what she has to do, but no more, thinking “if I’m not paid to do it, it’s not my responsibility”. Danielle feels like her life is pretty good, but she has one eye on retirement.

One day at work, Danielle starts experiencing neck and shoulder pain, and she recalls her mother having something similar due to her work as a seamstress and thinks to herself that it “must be genetic”. After talking to a colleague whose partner, Danny, had a similar problem and was able to resolve it after consulting an osteopath, she books an appointment with the same osteopath.

When she arrives for her consult, they discuss a treatment plan and get started. After a few days, there has been no change and Danielle loses motivation to do her home based exercises. She continues treatment for a few more weeks, as she enjoys the way manual therapy feels, but she is disengaged. After 6 weeks there is no change, and she is convinced her original thoughts were correct, and that her pain is “genetic” and “there is nothing she can do”.

Your Mindset Affects Your Behaviour

It should be obvious who has the growth mindset, and who has the fixed mindset, and as you can see, your mindset permeates every aspect of your life, including pain.

Having a growth mindset meant that Danny saw his pain as something that could be changed, if he changed what he was doing and improved (his knowledge, his body etc).

Having a fixed mindset limited Danielle’s recovery, as she saw her pain as her destiny (genetic), and thus was not inclined to try and change or help herself.

While pain is never simple, there are so many unseen factors, we can control much of our reaction to pain and what we do in the future. If you have the belief that you can grow and improve throughout your life, that it is likely this will extend to your beliefs around pain.

Can You Change Your Mindset?

This is the trickiest question to answer. People with a growth mindset will believe so, but people with a fixed mindset may not.

The science is unequivocal – our brains are plastic and can continue to change as long as we are alive.

As we change our thoughts and behaviours, our brain structure changes too.

If you want to change your mindset (wanting to change is key), then the best way is via actions.

You see, our brains are funny.

When we sit idle and think, especially about the future, our brains can get very creative. This can be a positive if you start thinking about where you want to be in 5 years and what you have to do to get there, but not so much if all this thinking does is keep you idling in place for another 1/2/5/oh-shit-where-did-my-life-go years.

It’s even worse if you start getting into negative thought spirals.

However, if we take action, any action, then our brains can’t get carried away. And, if we are smart, and start small, then we achieve a little success, we build confidence and momentum. Repeat this process long enough and you become a different person.

This, in essence, is mindfulness, but let’s call it something else – let’s call it momentum. Create momentum by starting small and before you know it, you have changed.

Really, My Back Hurts, How Does This Help Me?

In essence, it all boils down to this: are you resigned to having pain or looking for someone else to solve your problem (fixed mindset), or, are you willing to adapt, change and do what it takes to help yourself?

Some conditions are very easy to recover from, others very hard. What doesn’t change though, is that if you have no doubt in your mind you will improve, no matter what it takes, then you probably will*.

 

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.

 



 

 

 

References

(1) Wikipedia – Carol Dweck: https://en.wikipedia.org/wiki/Carol_Dweck

(2) Stanford News Service – Fixed versus growth intelligencehttp://news.stanford.edu/pr/2007/pr-dweck-020707.html

(3) NY Times – If You’re Open To Growth, You Tend To Grow: http://www.nytimes.com/2008/07/06/business/06unbox.html

(4) Brain Plasticity and Behaviour – https://www.psychologicalscience.org/journals/cd/12_1/Kolb.cfm

 

*Please don’t take this the wrong way if you suffer from chronic pain. This isn’t meant to belittle your pain or say you are not trying. The recovery rate for chronic pain is quite low, but many people learn to live fulfilling lives and manage their pain quite well. In part this comes from re-shaping their thoughts, emotions and behaviours around pain. Cognitive Behavioural Therapy (CBT) is quite helpful in this regard.