"I just started working on my forearm and it felt 100% just minutes into it! Yay - I can go back to work! Can I go to the gym to lift weights tomorrow?"
This young man had suffered the progressive onset of forearm and wrist pain over several weeks. He works as a labourer while studying and is a very keen gym-goer. The pain and weakness became so disabling that he was laid off work.
Under Accident Compensation (ACC) he was referred to a physiotherapist who is a hand specialist. The treatment given was to place the forearm in a brace, tell him to expect to be off work and exercise for at least 3-4 weeks, book him in for another session in a week and send him home.
He was distressed when he contacted me. There he was, in his flat, unable to work, unable to go to the gym, no money and facing the prospect of not being able to work for as long as a month. He could not even afford one week off work, let alone longer. Treatment with the hand specialist was going to cost $10 per session, plus the cost of getting there and back.
If he was an All Black and not a labourer, would his treatment have been any different? Of course, it would have been very different. He certainly would not be placed in a brace and sent home for a week.
If he was an All Black and not a labourer, would his treatment have been any different?
Since he was in New Zealand and I was in Quebec, Canada, we had a video-conference. It appeared that he had muscle spasm of the forearm extensor muscles. This is very common in sports like paddling and rowing and also among butchers using blunt knives.
I set him up to do self-deep tissue massage and release techniques. He was to do these daily while being welcome to wear the brace between sessions if he felt the need. I also arranged for some nutraceutical supplements that aid healing to be sent to him.
The end result is that he reports being completely pain-free within the first few minutes of commencing the massage and release techniques. He will be back in the gym and back to work by the time this article is published.
I have asked him to keep his appointment with the hand therapist because to cancel it at late notice will cost him $30, whereas turning up will be just the $10 surcharge on top of what ACC pays the therapist. He is welcome to tell the hand expert my opinion that she has done this young man a disservice and that she needs to improve her game.
He was instructed to continue the self-therapy daily regardless of whether or not he was free of pain and weakness.
The absence of symptoms does not necessarily mean the absence of disease.
In 1977 I was recruited by ACC to set up their sports safety and and rehabilitation programme. This included liaison with professional groups like sports medicine doctors, physiotherapists, podiatrists and occupational therapists. For these professions, ACC was a huge and delicious honey pot. Some unscrupulous practitioners did not just taste the honey with their finger tip, some jumped in right up to their necks, some outright wrought the system. While ACC now has much better systems for detecting abuse, as compared to those early days, what has not changed is that there is no real reward for effective treatment, the only reward comes with file closure. File closure is not always consistent with a cure.
File closure is not a cure.
A therapist may be permitted something like 6-12 treatments by ACC of a patient with no questions asked. The only real measure of interest is whether or not the patient is discharged from the ACC system. The therapist is paid and the patient may end up on a sickness or unemployment benefit. For ACC this is still a treatment success.
Real therapy of musculoskeletal injuries such as this labourer's powerful forearm, requires a good deal of physical effort. It is hard work and hard on the therapist's own forearms and hands. This can be especially tough on a new therapist who may be petite in stature as compared to the stocky and muscular patient. It can take years for a physical therapist's own hands to harden to the demands of the job.
The temptation, or survival response of the therapist, is to find ways to take it easy. The pressure is on the busy or struggling therapist to resort to machine therapies or other treatment modalities like acupuncture that require little or no physical effort. After I left ACC I was opened a rehabilitation service to ACC that ran from 1984 to 2001. I kept insisting on providing real physical therapies that produced measurable imporvements in health and function. I resisted the constant pressure from my physiotherapists to water down these treatments in favour of labour-saving modalities, the most popular being ultrasound and acupuncture at the time. It was a never-ending and frustrating battle.
The temptation, or survival response of the therapist, is to find ways to take it easy.
Effective physical therapy can cause pain and things may get worse before they get better. There is a constant fear among health professionals of a hostile patient making a formal complaint that the therapist was uncaring, unprofessional and hurt them. If this were to happen this can be a professional death sentence. You never know who is going to have a go at you. So there is the tendency to always play it safe with patients with the result that the therapy may be dumbed-down to the point of it being largely ineffective.
In the case of this student-labourer, it is safer and much easier to put his wrist in a brace and send him home than to do manual therapy such as painful deep tissue massage.
Remember, folks, you are the ones who are paying for poor physical therapy by way of your ACC levies that taken out of your wages and motor-vehicle levies. This may amount to many millions of dollars of treatment waste that we are all paying for.
Please do not accept sub-standard treatment. Demand the best and complain if it is not delivered.
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