The Bigger Picture

The Guardian today carries a piece that includes:

Radical changes are needed because the NHS will not be able to train enough homegrown GPs or recruit the numbers needed from overseas to surmount the growing shortfall, said Richard Murray, chief executive of the King’s Fund.

“We can’t GP our way out of the problem. Around 20% of patients that see GPs are there for issues ... such as back pain. This is exactly what physiotherapists are trained for,” he said.

Trials of giving patients with musculoskeletal conditions rapid access to a physiotherapist rather than a GP had proved successful, and physiotherapists could take over “a significant workload” from GPs, he said.

It is clear that the problem of the poor quality evidence base for therapist-delivered treatments in ME is part of a much bigger issue with therapist-delivered treatments and the drive to cut costs.

There is no evidence as far as I know that physiotherapy is any good for back pain - the 'evidence' is much the same as PACE.

While I think the thrust of S4ME should be ME advocacy I think it may be important to see how much wider the relevance of our discussions may be.

The medical professional community needs to wake up to the fact that the evidence base for these treatments is phoney.

It is not that we need more GPs though. We need more specialised physicians with expertise. The GP system is not working simply because it is being used as an additional unnecessary 'gatekeeping' step in proper medical care. The way to save money is to allow people to access hospital based care directly.

 

Wasn't the back pain issue how this all started with Waddell claiming that it was best cured by exercise, and selling the idea to Aylward?

 

Anecdote. I went to a physio with a bad back, he told me most people get better from their initial pain, within 6 weeks, regardless of what they do. But, he said everyone attributes their improvement to whatever they did the week before they got better. (often physio)

No improvement means surgery in a lot of cases that I know.

Personally I find painkillers, anti-inflammatories and muscle relaxants useful, so that means a trip to the doctor, not the physio.

 

We already have this. You can self refer to an MSK unit via website or phonecall.

 

Well said.

And on what I think is a related point, I believe we used to have more specialist/ consultant grade 'general physicians' to whom primary care GPs could refer complex chronic disease cases, like ME/CFS. That might help.

 

Really? Haven't read the studies but that would very much surprise me. I always thought that the reason why this intervention was so easily accepted in ME/CFS was that it worked reasonably well in other patients such as those with low back pain...

 

I think the problem is that this subculture unblinded trials with subjective outcomes has been trogging along for the last forty years in the area of therapist-delivered treatments. For some reason it got taken on by MRC as a respectable venture (probably for the same political reasons). As a rheumatologist I saw back pain problems throughout my career but gave up referring to physic in about 1982 because there seemed to be no reliable evidence anything made a difference. Further studies were done since then but the last one I remember bearing about was from Holland. Patients were divided into groups who exercised, or rested, or did what they thought was sensible. The best results were in the group that did what they thought was sensible.

I may be wrong but I doubt there is any reliable evidence. It would be pretty surprising if there was because back pain is heterogeneous and mostly self-resolving atlas for acute episodes.

 

Very likely so.

 

https://holeousia.com/2019/03/21/its-boom-time-in-industry/

Unfortunately the customers have begun to realize it's a scam. CBT/GET don't work for ME/CFS and probably not for MUS either, and IAPT is delivering very poor results.

 

Surely that must be a spoof. Could anybody be so lacking in awareness?

 

Its interesting fact that Mark Baker told me in January 2018 at the engagement meeting, that only two NICE Guidelines have ever been reviewed and 're written".
Back Pain and ME!
Gorden Wadell I believe ( following his death) had his adopted and promoted BSP approach discredited.https://dpac.uk.net/2014/09/gordon-waddells-biopsychosocial-attack-on-disabled-people/

 

From a personal perspective I cannot fully agree with that, if you mean it is no good for any sort of back pain. A few years back I was getting pain in my back and legs, and was referred to a specialist who did x-rays, and advised there was an issue with one of the discs, the symptoms of which included referred pain as if in my legs. He explained that part of the problem was that my core musculature was not very good, and that sorting that out would improve help alleviate the stress on the disc (it was a relatively mild issue), so best to try addressing that first. So he referred me for physiotherapy, and I have to say the various exercises and education she helped me with worked wonders. And no way were the original symptoms imaginary, nor was the improvement of them.

But of course that was a very specific kind of back problem, and it was thoroughly investigated and diagnosed. I fully appreciate that for other kinds of back pain physio might be useless, or maybe even harmful. The idea of short-circuiting the investigation and diagnosis process would be very scary.

 

No idea if physiotherapy works for back pain and so on, but I can say that my physio knows a lot more about the anatomy of the body than my GP does.

 

But that tells us nothing @Barry, because pain like that tend to get better anyway. You have no way of knowing whether or not the exercises 'worked wonders'. The controlled trials I have seen suggest that 'being sensible' is just as wonderful.

And there is no suggestion anywhere here that symptoms are imaginary. I had a look at Waddell's papers on PubMed and I was amazed that there was so much emphasis on 'illness behaviour'. I have looked after hundreds of people with back pain and never doubted the pain.After all I have been cursed with back pain all that time myself. Degeneration of the two bottom lumbar discs occurs in a very high proportion of people.

 

Physios do know more anatomy but they have very little grasp of how you tell what causes what.

The idea that muscle strengthening exercises helps joint or back pain has been pretty much debunked as far as I am aware.

 

If patients decided to be sensible and were allowed to exercise commonsense, we'd need less staff in the NHS.

 

I see no reason not to think that patients already are sensible. It is sensible to go and see a doctor with problems that 80% of the time are not to worry about. The whole point of seeing a doctor is to find out the 20% of times when you do need to worry and ordinary people are not in a position to tell.

 

I'm surprised at the limited reaction to post #9 from @strategist . [ https://www.s4me.info/threads/the-bigger-picture.8683/#post-153339 ]

I'm absolutely gobsmacked and furious about it and would have expected lots of angry responses within minutes!

 

Give it a little time, @Arnie Pye people are tired after the last few days, activity on the forum has gone done significantly after the onslaught on Monday and Tuesday. I for one don't have the capacity to read or react right now

 

From what I can see, medicine seems to be about as clueless about chronic back pain as it is with ME. I often see references that it's mostly psychosomatic. I just don't get it, it should not be controversial in the slightest and yet the debate continues for decades. Pretty much everyone taller than 180cm or so seem to experience it it's not like it's some super complex or hard to see a pattern and still sometimes you just have to wonder if we're all in Westworld because pretty damn obvious things don't look like anything to the people whose job it is to understand things.

I get it, subjective experience and all but when something (I don't believe you therefore it's not real) clearly doesn't work, to keep going for decades is just absurd.