Empowering patients and delivering impartial tendinopathy care

Empowering patients and delivering impartial tendinopathy care

Three important buzz-phrases in healthcare currently are patient-centred care, evidence-based medicine and working alliance. They are related.

• Patient-centred care focuses health professionals on treating patients with respect and appreciating their values and preferences.
• Evidence-based medicine focuses health professionals on not only considering the evidence and their experience but also patient values in care decisions.
• Working alliance is about developing a functional health professional-patient relationship and ensuring everyone agrees on the planned treatment and goals.

This short blog is about one common theme that runs through all of these - ensuring patients understand their treatments options (and the benefits and harms of each) in order to make informed decisions. It is our responsibility as health professionals to help patients get there. There are challenges from the patient and health professional side. For example, patients will tell you ‘how am I supposed to know what to do, that’s your job’. As clinicians a huge challenge is being impartial. We all have our own preferences and biases as clinicians, generally based on our training and experience.

Here are five strategies I use with tendinopathy patients to help deliver the evidence impartially and honestly:

1.       Admit that the tendinopathy evidence base is not great. It takes a lot of pressure off you, the health professional. You feel yourself relaxing a little as the words come out. You also move away from common industry specific biases (e.g. ‘exercise is the best treatment’ bias that physios often adopt). I make a point to tell patients that the evidence base in tendinopathy is not very good and our treatments are still being developed. There are no clear winners. Exercise is great for making you stronger and more functional (if you need this) but it is not clear if/how it impacts tendinopathy pain directly. As health professionals, although challenging, it is important to embrace uncertainty in clinical contexts. Don’t be like Robert Palmers’, Johnny ‘Johnny's always running around, trying to find certainty’

2.       Use resources that help to summarise the evidence. For example, the recent Dutch clinical practice guidelines for Achilles tendinopathy provides really helpful and relatively simple synthesis of the evidence and recommendations (look for the boxes). There are also lots of other helpful reviews and resources that we can use with lower limb tendinopathy patients. I discuss these in detail in my courses (here's a link to upcoming F2F courses in the UK).

3.       Be knowledgeable about the benefits and harms of treatment within and outside of your scope of practice. In some of our group’s research we have found that physios tend to shy away from educating people about injections and surgery.  This makes sense, it is not really what allied health professionals are trained in. The fact is though, allied health clinicians often practice in primary care and you may therefore be one of the first people providing education about treatment options to a tendinopathy patient.

4.       Don’t be wedded to any treatment approach. Using exercise as an example again, there will be tendinopathy patients who don’t want to exercise, or for some reason exercise is not a suitable option. Others hate injections. Etc, etc. Be armed with other interventions that you can offer. For example, there is evidence that shockwave therapy and heel wedges may be as effective as exercise for Achilles tendinopathy, and these may be suitable otpions for some. Exercise does not always need to feature. 

5.       Listen to your patients’ intuitions. We have all experienced patients who have tried exercise and failed. Our immediate reaction is often to think ‘yes, but did they do it adequately?’, and proceed to provide compelling arguments to repeat the intervention. This may be appropriate in some cases, but in my experience, it is never appropriate if there is substantial doubt in the patient’s mind. That should be respected.

Don't get me wrong, exercise is a great intervention for tendinopathy and features for many people. I talk in detail about how to individualise and maximise benefits of exercise in my courses. We also have to be honest about the overall state of the tendinopathy evidence and allow pateints to make informed decisions based on that.