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Conservative vs Surgical/Medical Management
There is an increasing wave of scientific evidence to suggest that surgical and medical management of persistent pain is no more effective than weight loss and physical activity in managing a range of conditions that include shoulder impingement, osteoarthritis (OA) of the knee and hip, and lower back pain.
The Royal Australian College of General Practitioners (RACGP) recently released new guidelines that recommended non-pharmaceutical, non-surgical approaches in the management of hip and knee OA. Furthermore, they strongly recommended against the use of opioid medications, acknowledging the low quality of evidence that supports their use. They were also critical of an over-reliance on costly and unnecessary medical imaging, stating that it was often misinterpreted and lead to risky and harmful interventions. Similar approaches have also been recommended following studies into the most effective management of shoulder impingement and lower back pain.
There are of course instances in which an individuals persistent pain may fail to respond to an extended period of conservative management, and in those instances surgical and medical management may be indicated. Even so, conservative management shouldn’t be considered a waste of time, as strategies such as weight loss and physical activity act as “pre-habilitation” that can assist in enhancing the outcome post-surgery.
What is a Physiotherapists Role in Managing Persistent Pain?
Physiotherapists can play a large role in the conservative management of persistent pain, in a collaborative, multi-disciplinary approach with other members of the allied health team, e.g. dieticians, exercise physiology.
- Education: Physiotherapists can address incorrect beliefs and negative thought patterns surrounding persistent pain and findings on medical imaging, and explain the process behind persistent pain so that it is better understood. This can help ease or even remove common emotions such fear and anxiety that typically develop in response to these thoughts and beliefs. If not addressed, these emotions can have a negative impact on persistent pain by causing the individual to withdraw from physical activity, and can further “increase the volume” of pain.
- Muscle Strengthening: Over a period of time, in response to persistent pain, the body naturally offloads or “favours” a painful area, leading to unhelpful movement patterns, deconditioning and the development of weakness. This can result in a painful region that has even less support than it had before. Physiotherapists are skilled in how to teach an individual to move, load and strengthen the painful region in a safe and controlled manner, to un-do the deficits they develop as a result of persistent pain.
- Physical Activity: It is well established that remaining active with some form of structured exercise, such as walking, cycling, or swimming, is beneficial in reducing pain sensitivity and helping to “turn down the volume” on persistent pain, as well as reducing stress and having a positive impact on weight control, sleep and wellness. Physiotherapists can assist in determining the most appropriate type and amount of exercise for each individual, provide guidance on how to introduce it, and gradually increase it- to avoid “pain flares” that can often occur when activity load is suddenly increased.
- Manual (Hands-On) Therapy: Although the previous three points are the MOST important aspects of managing persistent pain, short-term manual therapy can also assist in reducing pain-levels, allowing an individual to cope better in their everyday life and to progress through their rehabilitation. Physiotherapists are skilled in areas such as manual therapy, massage, and dry needling- all of which can provide symptomatic relief, assisting an individual to progress toward their long-term goals. Physiotherapists also teach self-management techniques, to enable the individual to be as independent as possible in managing their condition.
Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial- The BMJ