Find the dysfunction and fix it- the traditional therapy approach
Therapists (and I mean all therapists: chiropractors, massage therapists, physios, osteopaths, sports therapists) love to find things wrong with you. We love to find things about you that are abnormal. It gives us a way of explaining your problem and we can then suggest solutions. That is what therapy is, right? We are not alone in thinking about pain in this way. Much of medicine is based on this approach. Surgeons are reliant on it and surgery would be non-existent if it wasn’t for this approach.
However, within the physiotherapy community at least, there are increasing numbers who are questioning what is abnormal. Emerging science is showing us that body position and the way it moves often has little or no relevance to the problem a person is experiencing. Structural things such as tilted pelvises, weak core, overpronation, poor posture, patellar maltracking, leg length differences, amongst many others are often only small parts in a bigger picture. The science tells us these variants are often poorly related to pain.
Many people have these features and have no pain. For example, if you watch any athletics event on the telly many of the worlds’ top runners overpronate. Andre Agassi won the US Open despite having a grade 2 spondylolithesis. Usain Bolt has a large scoliosis. Pain is not simple (see my pain article) and cannot solely be blamed on the way our bodies move.
Are deficits and dysfunctions actually normal?
Our bodies are designed to be different. “Normal” has a wide boundary and each of our bodies will adapt to what is normal for us. It is all too easy for us as therapists to find ‘wrong’ in patients and offer solutions. Those who have seen more than one therapist may have had more than one anatomic ‘wrong’ pointed out. This is because lots of them exist in each and every one of us. Two different therapists will often come up with two different diagnoses. We as therapists are prone to our own biases.
Structural and biomechanical problems are often quite subjective and difficult to measure. This only makes their identification more dubious. Therapists can make things pretty complex. It is not unheard of to hear things such as ‘such and such told me my back pain is due to my big toe, it sticks out, makes my knee fall inwards, which twists my hip and puts pressure on my back”. The complexity does not mean that it is right. It sounds like it should be, but in fact I think quite the opposite; the more complex it is, the less likely it is to be true.
Problems with the deficit / dysfunctions model
The problem with identifying and trying to correct these “deficits” is that it can make trivial things appear serious. People spend considerable money and time trying to correct problems that their therapists have found. In truth they often may not need to be fixed. Equally true often structural issues often cannot be corrected, its your anatomy, it’s fixed, it’s how your body has developed. Unfortunately, by making you aware of these ‘defects’ a therapist may make your symptoms worse (see why does it matter how treatment works article). Therapists (and again I mean all therapists) are sadly sometimes part of the problem.
Final Thoughts
I like to take a more open approach to diagnosis and treatment. Rather than overcomplicate things I prefer to keep things simple. There is no point targeting something we can’t change. My job is to make you strong, our bodies can cope with anatomical disadvantages when we are strong. My goal is to make you feel strong, our bodies are not fragile nor vulnerable. My job is to return you to optimal function, to get you doing the things you need to do. Building capacity, building resilience but not trying to change that blasted big toe!
Thank you for reading, I hope it has raised some questions. Get in touch if you would like an honest, and open assessment about your problem. This is an introduction to a series of articles looking at myths in diagnosis, very much in the same vein as I did before with treatment. Look out for subsequent articles discussing many of the things discussed above in more detail.