In the UK Patients love Massage!

There is nothing inherently wrong with massage, it does reduce nociceptive feedback from a local injury site, it does help the nervous system find a parasympathetic state ‘rest and recovery mode’, it does aid the body’s lymphatic process of removing dead cells and inputting fresh blood into the area.

What it doesn’t do is offer long term changes to the strength or length of soft tissues, and very often this is what is missing when we obtain an acute injury. Not to mention the fact that when expectations are not met, this can lead to a mistrust of the practitioner and the treatment.

Another post comparing differences between UK and Nepal Physiotherapy

 

Electric Kathmandu

In Kathmandu, I was interested to discover the expectation of patients for a long time has been electrical modalities. The outpatients physiotherapy department was littered with Japanese devices from the 70’s, and if your treatment didn’t consistent in part of at least one of them, the person was wont to feel hard done by. The younger Physios in the department saw this as it was, a helpful ‘buy in’ to ensure compliance of home exercises. The older Physios felt, perhaps slightly out of date, that these devices were an essential part of the treatment.

We had traction machines, therapeutic ultrasound devices, TENs machines, low frequency stimulation machines, high frequency stimulation machines and what was very impressive, a brand new Shockwave machine. I can’t tell you a great deal about most of these devices as they didn’t form a part of my training. We were told these devices had minimal effect on healing at best. Except Shockwave, a device intended to ‘restart’ healing back to the inflammatory stage by creating micro tears in the tendon structure, useful for acute on chronic tendinopathies. Something a lot of physio’s at home would love to have in their office!

High Frequency Machine TENs Machine Kathmandu Expectations

A session would usually begin with a few minutes of a device then move onto the exercises for home. Advice would be given and the person would be told when to attend for the next session.

I was impressed with the follow up times in the outpatient department, whereas at home in private settings this could range from a few days to a few weeks to at worse a few months in the NHS, the outpatients department in the university teaching hospital had the capacity to call people back on a daily basis, should it be required. The cost for treatment whilst not free was subsidised and was approximately a few pounds a session. This obviously would limit the most impoverished from utilising the service.

Pills Please

A second expectation not only within the city setting, but the health post settings was that of always receiving medication. This didn’t surprise me, its not uncommon to experience this at home as well, but here it felt inflated. Most patients, with any amount of pain visiting the outpatients, already had a strong painkiller being used. If they didn’t, it wasn’t because it wasn’t wanted, but that it couldn’t be afforded. In the health post setting, if a person came in with symptoms indicating a common cold or other viral infection, antibiotics were being given. As standard. I didn’t see a person leave the health post without something, be that analgesia, antibiotics, antiparasites or topical cream.

I had one lady come in to see me at the outpatients clinic for lower back pain, however she flat out refused to complete an assessment or move her back in any way. Even though she had just walked a mile uphill to get there with a baby on her back. We, through translation, explained the requirement of assessement and the safety in movement to help but she was not consenting. In her mind: Medication. The one and only solution.

I didn’t manage to change her mind that day, but I also didn’t let it affect my mind. In the past I would have been somewhat taken aback at a unhelpful mindset, but this ladies belief system was based on the environment it was formed. I, a random professional, coming in ‘helicopter mode’ was not going to change things. A helpful discussion instead was made with the Health Post co-ordinator with basic physiotherapy advice that they could administer and give when appropriate.

Expectations Effect Everything

Expectations are nothing new. Not only do they effect what is done in the session, but they can affect how well someone improves. Physio’s are very aware that this will be an ongoing battle to continue to educate and suggest more effective forms of treatment, that is if they themselves believe in the treatment. The fact that we as Chronic Pain Physiotherapists understand the fundamental need for education on pain and an open minded discussion on mental health as a key signifier of pain presentation is a large step forward. It is so key that we keep having this discussion.