The Danger of Knowing

I wonder if we ever really know as much as we think we do.   A recent article in Spine (1)  looked at GPs with a self described special interest in musculoskeletal or occupational health medicine and their management of patients with low back pain.  The conclusion drawn by the Australian investigators was, ‘A special interest in back pain is associated with back pain management beliefs contrary to the best available evidence. This has serious implications for management of back pain in the community.’  In other words, those GPs who believed they were more ‘expert’ were actually the opposite!

It got me wondering about the risk of ‘knowing’ something so well that we cease to refresh or challenge our knowledge base.
For example, I have a special interest  in shoulders.  I have written and taught about shoulders for over twenty years.  Yet, how many shoulder workshops have I attended that I didn’t actually lead?  Maybe one every couple of years.  Post-graduate university teaching and delivering at large conferences have obliged me to try and keep up with other work, but I am only human.  And one of our human limitations is the ability to blind ourselves to new information when it suits us.  To hold a strong position and then avoid, disregard, mis-interpret or bend new information so as not to rock the conviction already held.  I love finding research articles that support my clinical observations and the foundations on which I treat patients.  I share these papers,  use them in my reference lists and acknowledge the wisdom of the researchers.  Upon reflection I suspect I treat papers that don’t resonate with my beliefs and practices somewhat more cursorily.   Beyond that, I am sure many colleagues jump on the very papers I underestimate and embrace them enthusiastically because they experience a  resonance with them.  Academic rigor in research demands a review of relevant published work even those not supporting hypothesis.  To keep an open mind pending the outcome. Outside of the research environment there is no such imposed balance.

Knowing stuff can be dangerous.  You can retreat to a comfort zone of ‘well that’s that, I understand it now’ and cease to be open to new, different, complementary or even opposing views.

Knowing stuff is cognition.  Knowing that your knowing is incomplete and is subject to your attitudes, prejudices, bias, expectations and experience is meta-cognition –  the ability to rise above your ‘knowing’ and perceive that your knowledge base is a mere speck of sand on the wide beach of what you do not yet understand.  Maybe this is the difference between knowledge and wisdom.

Just like the GPs who believed their ‘special interest’ afforded their patients an advantage, I suspect any complacency in our information quest will impact on our patient care.

That said, I am now going to register for a shoulder workshop…


1.Buchbinder et al, Spine: 15 May 2009 – Volume 34 – Issue 11 – pp 1218-1226

‘Which Pillow is Best?’

I must have been asked this question about a million times during my time as a clinical physio.  Plus another half million at various social events!  Perhaps I am exaggerating, but it sure is a common question from clients with neck pain; especially neck pain that interrupts sleep quality.

In my attempts to find the ‘perfect pillow’ I have recommended and sold many different pillows in the clinic – feather filled, contoured, tri-compartmental, latex, mixed, kapok, foam and probably a few others.  I have just had a look on Google and pulled up a whole new range from which to choose – Euro pillows, boudoir pillows, Lap pillows (shaped like a lap!), Pirate pillows (true), traction pillows, pillows filled with silk or wool, pillows that play music and even one that has an inbuilt alarm that lights up as it wakes you!  None of which will probably help my clients.

Research on the optimal pillow is not strong.  However Dr. Sue Gordon (a physio at James Cook Uni in Townsville) has done extensive research on sleep position and waking neck pain.  She found that ‘subjects who reported that they slept mostly on their side were significantly less likely to report waking cervical pain or waking scapular or arm pain compared with subjects who slept in any other position (1).  This is useful, but still doesn’t address the ‘which pillow’ question.

So I got thinking – a lot of my advice to clients when trying to change pain patterns associated with position is to ask them to avoid sustained positions.  To move the body area that is painful.  This alters postural loads, changes lengths of structures, pumps fluid through the area, dampens the incoming pain signal by stimulating proprioceptive afferent nerve fibres, distracts them and gives them a degree of control as opposed to being a ‘pain victim’.  Might not the same idea apply to pillows and neck pain?

For the last year or so my response to the ‘which pillow’ question has been ‘your next pillow’.  My advice is to have two or three different pillows and to rotate between them on a two to four weekly cycle.  My idea is to prevent them using the one pillow style for long enough to adapt to the particular support mode and posture associated with that pillow, and instead introduce a different support/posture interface on a regular basis.  The short turnaround seems to reduce the initial discomfort of a pillow change and the regular change might be the equivalent of a postural position change in (say) a workplace situation.

This is in no way a thorough study on pillows and neck pain.  But my initial impressions are that this system firstly does no harm and secondly can improve waking pain and sleep quality in some clients.  Whether this occurs at a higher rate than placebo or another intervention I cannot say.  I will leave this up to a research minded colleague to determine.

Meanwhile I would be interested in any feedback from clinicians out there as to whether they have tried anything similar, or indeed a different strategy that has proved effective. Feel free to leave a comment, below.  Meanwhile, Dr. Gordon has some useful information on pillow types, selection and sleep facts on her website –

1. Gordon S.J., Grimmer K.A., Trott P.  2007  Sleep position, age, gender, sleep quality and waking cervico-thoracic symptoms. Internet J. Allied Hlth Sci. & Prac. Vol 5 No. 1.


Work Life Balance…..

I love motorcycle touring.  Today I met up with a bunch of like-minded mates and we took off for 300km around the hinterland of South Eastern Queensland, Australia. Stopping for ‘smoko’ and lunch gives us a chance to tell a few lies and laugh at a few stories.  Later this month I am combining motorcycling and work when I conduct my first workshop tour ‘on the road’.

Travelling south as far as Canberra, I will be delivering twelve “BizFizz’ workshops for private physiotherapists in rural New South Wales.  Four or five hours riding each day through some of the best motorcycling road in Oz, then after a walk, some exercises and a feed – four hours on the business of physiotherapy.  

Combining your passion with your work transforms the way you feel about your ‘job”.  Sometimes the links are obvious, sometimes it takes a little more innovative thinking.  See how you go.

The Red Sock System of Time Management

My wife, Mary,  says I have a ‘red sock obsessive-compulsive disorder’.  Something to do with my drawer full of red socks.  Have you any idea how much time you can save every day by not having to choose what colour socks to wear?  I reckon I must have saved (say) 60 sec per day for 20 years  PLUS the reduced sorting of socks in  the wash and pairing them afterwards!  This could add up to around 180 extra hours to pursue more important activities.   This is more than an extra week in my life. 

When looking to ‘manage time’ identifying trivial time wasters can turn small daily gains into leveraged cumulative results.