Nightmares In Health Care

I am sure you’ve experienced it. You are relaxing comfortably, fall asleep, then suddenly arrive at a terrifying dream in which you experience feelings of extreme anxiety. Then, you wake back up and realize it was all just a dream. It was nothing more than a nightmare.

I see the same thing in health care, and I keep hoping that I will wake up and realize it was all just a dream. But it’s not. As a PT in the sports world for 24 years, i have seen my fair share of nightmares in health care.  The most obvious and prevalent examples of these nightmares are the cases that are grossly over-treated or under-treated in the face of good scientific evidence and clinical reasoning – or lack thereof.

Sadly, these nightmares are recurrent in the world of sports medicine and orthopedics.

The nightmares aren’t the atypical cases, the rarities that are under-diagnosed or mistreated. No, those aren’t the nightmares in health care. The true nightmares are the common conditions that patients present with that are treated with methods that simply don’t have any scientific evidence, or just don’t make sense from the world of cellular physiology.

A good example is the running patient who presents with a diagnosis of posterior tibial tendonitis. The symptoms are intermittent with mechanical loading and have been present for over a month in duration. They came on with a sudden change in their training plan. The patient tells you that they were prescribed a variety of treatments. These include medications, the use of ice, performing active range of motion exercises at the ankle, stretching the calf muscles, self massage with a golf ball, and maybe even some orthotics thrown in for good measure. And they still aren’t any better.

In the same breath, the patient has not had physical therapy prescribed for them. If the patient mentions it, the referring practitioner oftentimes does so almost begrudgingly. “Just rest a few weeks, and then gradually resume your activities’, they often say.

Welcome to the “shotgun” approach to care. You are lapsing into the nightmare as we speak. Surely, one of these “treatment interventions” has to work, right? Seriously though – is that sound clinical reasoning? Or is that just throwing out a bunch of options with the hope that one of them will work at least as well as nature? The placebo effect could be the primary treatment intervention in that list. At this point in the history of cellular physiology and mechanical assessment, most of those interventions just don’t cut it.

Was this a tale of woe circa 1970? No. This was 2012. Yes, 2012. And the forecast for 2013 isn’t looking much better.

That, fair reader, is an utter disregard for cellular physiology, mechanical loading, and clinical reasoning as we know it. This “approach” to care is not only out-dated but it is absolutely not supported by the scientific literature. I would go so far as to say that it is one step from unethical to provide this as a “standard of care” when it is, quite simply, not within the realm of the past 20 years of our scientific understanding of cellular physiology and responses to mechanical loading.

Has a mechanical assessment been performed to establish the mechanical loading capacity of the joint and surrounding musculature? Do any of these “treatment interventions” actually change the mechanical loading capacity of the joint or change the patient’s ability to function on planet Earth?

That is just one example. In one clinic. Extrapolate this nation-wide and you have a scourge, a virtual epidemic, of running-related injuries that are being made chronic conditions.

When will professional associations – be they medical, physical therapy, chiropractic, or other – not only shun this approach publicly, but consider this a violation of professional association ethical standards? When will educational programs choose to build curricula around the literature and not just pay lip service to it? Perhaps more importantly, when will consumers choose to no longer accept this? When will consumers wake up from this nightmare?

Photo credits: Abi Skipp