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I have a thing for counterintuitive things. It’s one of the reasons I consider myself so lucky to have gotten into the MSK game when I did. It’s counterintuitive that the extent of tissue damage doesn’t necessarily correlate with pain and that moving ‘badly’ doesn’t necessarily cause injuries or impair performance. If it was clear and obvious, I’d have been less interested and less interesting. The murkier the water, the more comfortable I am… unfortunately that also got me sacked from running Evian…

As an inherent optimist and realist, I have benefitted from being able to present both hope and direction to patients engaging in rehab and colleagues keen to see our industry improve. Combining my optimism with my love of the counterintuitive is perhaps ambitious but I have in recent years found a way and it has helped my patients, colleagues and commercial partners in various ways. Let me introduce you to some examples of when we should wish things worse. The Region Beta Paradox [1] was described by psychologist Daniel Gilbert in 1998 when he and colleagues observed circumstances in which people recover quicker from a more intense negative experience. The general gist is that in situations of tolerable discomfort/frustration/unhappiness (Region Alpha), the threshold to take action isn’t met. Therefore the situation can go on for longer, become more integrated into your life and be negatively adapted to. So if the situation was worse - enough to inspire you to act (Region Beta) - you would at least have the chance to get over it quicker.

The ultimate counterintuitive thing I’ve noticed when explaining this concept to patients, colleagues and commercial partners is that they are very often both delighted to know about it and wish I’d never introduced them to it. They recognise the ways in which they are sub-threshold but felt pleasantly ignorant to the fact that they should probably act on it.

Clinically, the obvious examples are the annoying but not disabling conditions that people just live with, usually until they realise they are not able to function as well or as comfortably as they would like. The threshold is eventually met and they present for assessment but with a sometimes trickier presentation to treat. Might they have been better off if it had been worse? In such cases, I find it to be very important to unpack with the patient what has inspired action so that we don’t risk them judging our success purely on them hurting less. But that’s the low hanging fruit so here’s another way to apply the concept with patients: break their leg… We all know the patients with a condition which requires more relative rest than they’re willing and/or able to give it. In these cases, the pain and dysfunction is certainly beyond the threshold to seek help but not at the threshold for them to adjust their routine for a time to let things settle. Examples from my second opinion clinic this week; raging sub-acromial bursa in a mechanic; thick, angry achilles in a trail runner, and lumbar disc herniation in a Hyrox enthusiast. Especially having been mismanaged to date, I do understand why they were reluctant to make inconvenient adjustments. Self-employed mechanic ‘needs to get on with it’, trail runner ‘needs the hills to escape the kids’, and the Hyrox enthusiast ‘wouldn’t have anything to talk about’. So I push them over the threshold with a hypothetical, ‘I certainly hope you don’t but what if you walked out of here today and broke your leg?’. A conversation then ensues about the various awkward adaptations they would have to reluctantly make and then I make the case for us needing to dose what they’re doing in order to recover quicker.

On a wider industry level, I do wonder whether many of us are sub-threshold in Region Alpha tolerating wide variations in standards, ineffective professional bodies, political insignificance, underfunding and disunity. I’ve found myself wondering if we should ‘wish things worse’ as that might invigorate change and disrupt what many are tolerating but not enjoying. Is there a unifying project that can take advantage of a societal moment that seems ready for rehabilitation and the positive effects of its proliferation?

This month’s MSKMag is certainly not ambling along quietly and is full of spicy flavour. Celia Champion explains how to nurture good apples and identify bad ones, Ben Wilkins is back by popular demand discussing the gamification of rehab, Tim Allardyce ponders our ever evolving relationship with ice for acute injuries. Lewis Rawson made this editor sweat when I saw his title ‘Make MSK Great Again’ as he reflects on EBP in a red cap. Our weirdest feature Chewy & Jim is back and Rob Beaven gatecrashed our rant fest and finally, the inimitable Alistair Beverley, The LD Physio himself could have hung up on me when I asked him to write about an intensely delicate subject but instead stepped up and knocked it out of the park; ‘Beyond the ‘Licence to Kill’ Headlines: Assisted Dying and MSK Practice’ is our leading feature this month and is an absolute must read.

It’s an excellent Mag with many excellent points made by excellent thinkers. But will it inspire change in you? Will it meet the threshold for you to act? Or should we wish things worse?

Jack Chew