29 May First – Do No Harm!
The Hippocratic Oath is a pledge that all doctors take when they are first registered to practice medicine. It includes the well known and oft-repeated, “First, do no harm”, from the Greek ‘Primum non nocere’. This is certainly a good principle for doctors and physiotherapists to have in the forefront of our minds when we consult a patient; but sometimes it can actually lead us down the wrong path. How can doing trying earnestly to ‘do no harm’, actually leave the patient worse off and possibly even cause harm? It’s complicated but ‘over-protecting’ a patient can lead to deconditioning, catastrophising, learned non-use, re-affirming the patient’s mind-set and often missing out on key goals and life achievements.
When a patient is injured and books an appointment to see a health professional there is an expectation amongst both parties that the doctor will be lecturing the patient to rest and do nothing until the injury gets better and that the ever-eager patient will be railing against this and asking to be able to return to their normal activities. So often both parties are correct to assume these roles as total rest is required for the injury to heal. Nevertheless, with musculo-skeletal injuries, total rest is rarely the correct management.
As our understanding of the human body and recovery mechanisms improves, it has become increasingly clear that total rest can make some injuries worse, or at least slower to heal fully. Here are some examples of injury management that has changed over time:
- Tendonitis (Tendonopathy) Ten years ago the standard management for a tendon injury form overuse was basically: Total rest, stretching, anti-inflammatory medication and ice. But we now know that tendon injuries do much better when they are given the appropriate dose of loading and appropriate activity modification. Injections, shockwave, ultrasound and PRP may have a role but a loading program should always be the centre piece of management.
- Lower Back Pain Previously treatment for back pain was sustained bed rest, many doctors recommending as long as 2-3 months for relatively mild back pain. Now we know that backs generally do better when people continue to go about their usual daily routines.
- Acute Injuries When someone sustains a ruptured ACL traditional care was to be put in a plaster cast and recommend a long period of non weight bearing. Now if there are no other pathologies in the knee, we know patients do much better when kept moving and we commence them on a program soon after the injury and also post-operatively to prevent muscle wastage.
The difficult part of this active recovery is getting the exercise and loading dosage right for the person and their specific injury. Unfortunately there is no specific formula that will be suitable across the board. It is up to the doctor and physiotherapist to take in all the variables in the case and come up with the correct management plan.