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Too Much Medicine

Too Much Medicine

Too Much Medicine

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The current issue of the Journal of Orthopedic and Sports Physical Therapy includes an interesting commentary on a topic sure to generate some controversy.  Entitled “The Elephant in the Room: Too Much Medicine in Musculoskeletal Practice,” the authors pull no punches in outlining what they see as a problem in current physical therapy as well as physician practice that is contributing substantially to the continued upward spiral of healthcare costs in this country.

The authors define “too much medicine” as the unjustifiably excessive and unnecessary use of diagnostic tests or treatments for conditions that most likely will respond to the “tincture of time” or conservative care.  They also express concern for the “medicalization of normal” – when an ordinary human function or condition is labeled as “abnormal” and blamed for the patient’s pain.

An example of the former would be the ordering of an MRI exam for generic, non-specific acute low back pain; blaming so-called “abnormal posture” as the cause of pain is an example of the latter.  In both cases, there is ample scientific evidence showing that both practices are seriously flawed and questionable, and often lead to unnecessary, expensive interventions.  There are many more examples of this problem demonstrated by how we approach shoulder (rotator cuff “tears”), knee (meniscus tears), and hip (labral tears) pain complaints.

The bottom line for all of these conditions is that x-ray, CT, or MRI images that show alleged abnormalities are commonly used to explain a patient’s pain, despite the fact that very often the exact same images are found in the general population without complaints of pain.  Likewise, postural deviations are often used as a hypothesis of the cause of a specific pain complaint, while the majority of people showing those same abnormal positions (e.g., forward head, rounded shoulders, sway back) have no symptoms at all.

The authors list several factors to explain this phenomenon, ranging from the profit motive to a more altruistic motivation (healthcare providers want to be able to do something to help, rather than simply saying, “give it time”).  I believe, however, that the patient must accept a large share of the blame, mostly due to our increased reluctance to accept a simple fact of life: into each life, some pain will befall.

This refusal to recognize this unavoidable truth stems, I think, from our witness to the truly monumental advances in medicine over the past several generations.  We see the successes in combating or eliminating diseases through the use of antibiotics and vaccines; we marvel at the extension of the average life span that is in part attributable to amazing procedures such as cardiac by-pass surgery; we all probably know someone whose life has been saved by advances in cancer treatments.  We see these and ask – Why can’t they get rid of my knee/shoulder/low back pain as effectively?

I probably cannot answer that question satisfactorily; I can only say that musculoskeletal pain is a different animal from these other conditions.  (When I hear that question, I’m reminded of the recurrently heard plea – If they can put a man on the moon, why can’t they _______?)  There are so many causes for this type of pain, so many contributing factors, and so many questions we still have about the nature of pain itself, that it is no surprise we still struggle to address this problem adequately.

These days, I find myself more and more advising patients to be patient, to understand the nature of their problem as best as we currently understand it, and to accept that, indeed, these things take time.  We can try to help accelerate the recovery, but there are limitations.  Most importantly, I try to encourage patients in most, though not all, cases to take the most conservative, least invasive, least costly approach to resolving their problem.  And that includes acknowledging that formal physical therapy three times per week for 6-12 weeks is not usually necessary for uncomplicated (non-surgical rehabilitation) pain complaints.  In my opinion, most of these problems can be addressed with a prescriptive home exercise program you can do on your own.

Unfortunately, as the authors of the commentary note, there are many forces out there advocating for just the opposite, and impatient, uninformed, or simply fearful patients are too often willing and anxious to accept their suggested remedies.  Don’t be one of those people.