Do all patients need treatment to get well? How much
treatment does the patient really need to become well again? Who should pay for
treatments aimed at getting patients well? When considering some of these deep
questions, the Illness-Wellness
Continuum may be helpful. The Illness-Wellness Continuum was a concept
proposed by John W. Travis in 1972. This perspective is consistent with the
World Health Organizations view on health. Wellness and Illness are not seen as
distinct isolated items, but more of a concept that lie on a continuum. Let’s
look at the definition of the more black and white end points before getting
muddled into the messy grey middle. To be “well” by definition is to be in good
health, thus free or recovered from illness according to some definitions. How
then do we define “illness”, by some definitions it is a disease or period of
sickness affecting the body or mind.
One can see that it does not take long to potentially get
messy when we see symptoms and signs showing up on the illness side but maybe
could be on the wellness side. How many of you reading this have had what we could
call a bad day or feeling a just a bit out of sorts? Maybe you had a bit of
headache, upset stomach, a little soreness in the knee, an ache in the back,
feeling a bit down or depressed. Does this mean one needs medical treatment for
these things because they fall in the treatment paradigm? I would argue we need
treatment, but what that treatment is may not need to be “medical” treatment.
Maybe we just need the treatment of coping skills with using some reassurance
and time (natural progression and regression to the mean).
Nortin Hadler in his book Worried
Sick, redefines “well” as not being free from signs and symptoms and
feeling well all the time. But instead the ability to cope with the occasional
“bad day” or period of feeling out of sorts. Many a patient will come to us in
our clinics when they are in the middle of this feeling out of sorts period
because of their inability to cope with their current state and the uncertainty
of what potentially may be wrong with them on the illness side of the
continuum.
I’m referring to multiple treatments of signs and symptoms that current medical research tells us has little to no distinguishable value. Yes, I’m referring to improving someone’s core strength, posture, SI position, leg length discrepancies, positional faults and the likes for many regional pain syndromes.
Unfortunately, the medical community has made a very large
Medical Industrial Complex on over-medicalizing every little sign and symptom a
person might develop. This medicalization has left some
of us disillusioned. When a patient comes in with pain or dysfunction that
has them “out of sorts” we need to carefully assess them on this continuum. Do
they have a significant disease or injury that warrants additional care by a
health care provider. Maybe they just need some reassurance to help with their
coping and a bit of time to make it through the “out of sorts” period they are
in. How many “out of sorts back pains” or “out of sorts knee pains” and on and
on are treated medically. When I say treated, I’m not referring to the
evaluation that assures them nothing significant is wrong and at most could use
a couple treatments that are based on reassurance to help a patient cope with
their current predicament and help them move on feeling well again. I’m
referring to multiple treatments of signs and symptoms that current medical
research tells us has little to no distinguishable value. Yes, I’m referring to
improving someone’s core strength, posture, SI position, leg length
discrepancies, positional faults and the likes for many regional pain syndromes.
When the patient with these regional pain complaints gets better we self
justify the treatment by touting that we helped “fix” the “cause” of the
problem since in the end the patient is “well, i.e. recovered from their
illness."
Are these findings that are treated really something that is part of an illness, or just a normal sign and symptom we all experience at different times and maybe the person couldn’t cope during their time of being out of sorts?
We utilize our treatment interventions of choice as the what “fixed”
them category and the “cause” as some sign or symptom that we found and fixed. Many of the signs and symptoms we see treated
daily in PT clinics (and other health care clinics) that are the “cause” of our
patient problems and thus in need of treatment are actually just part of the
normal variation in the human population.
Grey hair is a sign and symptom of changes in the body and
not normal for many, should it be treated medically? Sure some people feel the
need to treat it with coloring their hair because they can’t cope, but should
this be paid for with medical insurance premiums that you and I help pay?
Should we cover a highly advanced and expensive intervention that might have
some increased risk involved to color someone’s hair when it shows to be no
better or marginally better at best compared to the simple less risky
intervention? But what if the patient says they want it and feel they will have
a better customer experience if they get it, should we give it to them? While
some of you may be thinking this is a silly example and grey hair and the
things you treat in therapy have nothing in common. Others of you may be
wondering if that sign or symptom you just evaluated on your patient really
needed fixing and see some potential similarities. Would they have gotten
better even if you didn’t fix their posture, do some Theraband rotator cuff
exercises, manipulated C5-6, stuck a needle in that trigger point? Are these
findings that are treated really something that is part of an illness, or just
a normal sign and symptom we all experience at different times and maybe the
person couldn’t cope during their time of being out of sorts?
I understand that it gets a bit tricky to fully know the answers
to these questions because there are lot of “it depends” when looking at
various signs/symptoms and treatments. Some seem a bit easier for many of us to
answer, for example the use of energy crystals to cure low back pain because we
evaluated a decrease in chi levels in our patient, doesn’t seem to be a
treatment that is needed. But what treatments are you using that may have
minimal effectiveness at best over others that are cheaper and have less risk
involved and that we have gotten use to using? I’m not arguing or supporting
doing nothing as some sort of nihilism approach or that there are not any
illnesses that come into PT and medical clinics that can benefit from
interventions that evidence has shown to be effective. We don’t need to throw
the baby out with the bathwater. But are there times there maybe isn’t even a
baby in the bathwater? At times do we need to consider reassurance and
immediate dismissal as a treatment after a thorough evaluation has shown us
nothing major is going on. We know if we search long enough we can find
something that needs treated. But if a patient and therapist are spending their
time trying to prove that they are ill, can the person really get well?
Okay, your turn, what say you?
Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!
Keeping it Eclectic...
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