Science, and the responsibility of administering it.

While studying physiotherapy I made some money selling coffee. Coffee offered a unique opportunity to explore the world through others’ world-views and experiences. I really enjoyed how coffee could accelerate the transfer of information, and make big ideas seem simple.

Life as a barista is curiously similar to that of a physiotherapist. Similar, at least, to the life of a neuro-immune informed biopsychosocial physiotherapist. I entered the world of coffee making at the start of a new era, but more on that later. It was a sunny summer day, and I had a little 125cc step through motorbike that went 80kms an hour. I had heard of some people in Melbourne who were leading the charge with specialty coffee, so I made a sandwich and set off over 700ish kms to find out more.

I rode through the night, and arrived first thing in the morning to a cup of coffee that was to expand my sense of possible. It was a little coffee that symbolised innovation, and the concerted and deliberate action of hundreds of people. This was the beginning of the third wave, a phase where coffee makers and roasters began to view coffee as the result of a complex system of interactions, all of which were important to achieving the final cup.

It is said that coffee is never better than when it is picked. Each step thereafter (processing, packing, transporting, roasting, brewing, serving) either maintains the quality, or takes from it. The job of a roaster or barista is to interfere with the coffee as little as possible, and be humble in knowing that the final product is not your creation, but the work of hundreds of people who came before. 

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Providing education is an important part of physiotherapy, perhaps the most important. This is because most injuries get better by themselves, and need little or no physical intervention to heal. Most injuries respond well to a few days of reduced activity, then a gradual return to movement as normal. In terms of research evidence there is very little to suggest that any health practitioner (e.g. physiotherapist, chiropractor, osteopath, massage therapist, etc) can speed this up.

This is contrary to what many have heard, and it is really important.

Most injuries heal by themselves. However, the experiences of many people suggest that even a simple injury can lead to long-term problems, including pain. As an example, many of my patients with back pain say they first hurt their back picking up something light from the floor. Their back has 'never been the same since'.

In the example above a very small injury leads to lots of pain that doesn’t go away. It is possible that this patient strained a muscle, or sprained a facet or intervertebral joint. These injuries are generally minor, and heal quickly. Initially the injured tissues send signals to the spinal cord, and these are transferred to the brain. The brain interprets these signals in context and decides whether they are dangerous, if they are interpreted as dangerous then you will probably experience pain, which is produced to create a useful behaviour change. Pain generally makes you become less active, and protect your back for a few days.

As mentioned, injuries generally heal very well. But sometimes the area stays painful long after healing has occurred. Repairing tissues is an obvious priority, and it happens as quickly as possible. And once the tissues are healed (6-12 weeks for most injuries), treatment directed at the tissues is unlikely to help.

Understanding why pain persists and what you can do about it is important, and this is something that a skilled physiotherapist can help you with. Then it is important to develop strategies to improve your function, and return to the things you did before you were injured. It is a worthwhile goal to ‘move like you did before’, or ‘gain the spontaneity and confidence in movement that you had before injury’. It is useful to find some goals that resonate with you to direct your action.

Teaching patients about pain is a seriously important thing. Most people arrive at our clinic confused by the competing opinions of their medical team, family, friends, and the internet. Unfortunately we often provide yet another opinion. Fortunately our opinion can often be more positive than those that came before, e.g. that tissues are strong, that they are safe to move, and that pain is no longer an accurate reflection of their tissue health. We arrive at this opinion through detailed diagnosis, consideration for principles governing tissue healing, and an in-depth knowledge of pain.

So why the talk about coffee? 

Like life as a barista, administering science is the final step in a long process of deliberate and concerted effort. The scientific community relies on us as clinicians to accurately communicate the message, and practice in a way that captures the best knowledge of the time. At this point in time the best science is telling us that pain is not what we previously thought it was. It is a challenge for clinicians and patients to accept and act on this knowledge, but if we deny it then it will only serve to slow progress. Providing patients with research-based pain treatment is being involved with the cutting edge of human knowledge, challenging established norms, staying optimistic, and staying grounded in the facts. Bit by bit research will offer improvements in pain treatment, and it is our job to leave preference at the door and offer treatments that accurately represent the science of our profession.