QUESTION: What do injured patients NEED more than anything else?

ANSWER: Well, it seems that what patients need is clear, factual, evidence-informed INFORMATION, delivered by informed clinicians in a respectful way. It seems it is more important that a clinic has clinicians (consultants, doctors, nurses, therapists) who LISTEN to patients’ concerns and questions and then RESPOND to them seriously. I have heard complaints from numerous patients that this has not been their experience with some previous clinicians.

There is a growing body of research supporting the notion that this is true. Below for patients and other physiotherapists I have summarized the findings of a very recent study in Lancet (reference below) which compared the effect two very different approaches for patients with chronic whiplash. The first treatment approach required 20 hour-long, physiotherapist-guided sessions of specific therapeutic exercises – the second approach consisted solely of a SINGLE 30 minute session of ADVICE about what to do if you have ‘whiplash’, and of course, what NOT to do. It’s important to note that the 20 hour exercise group also received the advice in the form of a booklet entitled “Whiplash Injury Recovery: a self management guide”.

All patients were followed up and reassessed at 14 weeks, 6 months and 12 months after the cessation of treatment.

Common sense dictates that 20 hours of treatment is ‘better’ than 30 minutes of “mere” explanation and advice and that the benefits of all this expertly prescribed and supervised treatment would be not only substantial, but noticeable and measurable. But this is in fact what DID NOT happen. Common sense is so often wrong, I’m tempted to rename it ‘uncommon sense’.

Patients in the group that had the 20 tailor-made, expertly prescribed and supervised sessions that consisted of ‘cutting edge’ exercises and drills, did not benefit any more than those who merely had the benefit of a sound explanation of their problem that was supported by the best scientific evidence available. Their pain did not improve any more than the advice group; their function did not improve any more than the advice group. The two groups started the clinical trial comparable to each other – and they FINISHED the trial with less pain and better function (as you might expect) BUT one group did not do any better than the other (as you WOULDN’T expect).

So, what can you deduce from this?

1. Explanation and Education (with empathy, “do’s & don’ts” and advice) are of the utmost importance for patients with acute and chronic injuries – possibly more important than ANY OTHER treatment approach in physiotherapy.

2. Patients who had 20 one hour sessions with expert providers of therapeutic exercise did no better than those who had scientifically supported, sound ADVICE about chronic whiplash.

3. There is a tendency for some patients to think that they received advice (explanation or education) INSTEAD of treatment. This study shows (as do many other scientific studies) that the advice IS THE TREATMENT, that it is effective and that it is important that they follow it. We are awash in information now – much of it merely well packaged utter rubbish; some of it dangerous rubbish. Telling the rubbish from the ‘good stuff’ takes time, experience and knowledge. Protecting patients from ‘modern myths’, bad advice, proprietary lies and dangerous nonsense is an important, though time consuming, part of the physiotherapist’s job. Good ADVICE is priceless – an essential component of every treatment session.

Michaleff et al. 2014Comprehensive physiotherapy exercise programme or advicefor chronic whiplash (PROMISE): a pragmatic randomisedcontrolled trial

www.thelancet.com Published online April 4, 2014 http://dx.doi.org/10.1016/S0140-6736(14)60457-8