Physiotherapy, come forward! (It’s time to step out from behind the curtain)
Paul is a physiotherapist and creator of the naked physio blog and podcasts, and has worked in the field of persistent pain over the last 10 years in the United Kingdom and currently New Zealand. Paul has a passion for helping people with persistent pain, providing skills to help them understand and learn to live well with their pain. You can check out his website HERE.
Everyday, I hear, read or see some issue surrounding public health. The increases in chronic disease, the financial strain on health budgets, people are less active, the rising cost in food, issues in childhood obesity. I do my best to access and read as much research as I can (to challenge my biases) to identify the diverse areas physiotherapy can have an influence on public health. It’s astonishing!
I write this blog because I feel now is the time to highlight how much of an exciting time it is for physiotherapy. I mentioned evidence in the intro because bloody hell there is so much that encapsulates the essence of physiotherapy. But… Physiotherapy is at a crucial stage of its evolution. I’ve highlighted this before.
The physiotherapy profession needs to do some major reflection if it wants to continue to be an influential player in the delivery of public health. It may surprise you but there is so much evidence (some we need to be mindful of) that supports the benefits of physiotherapy. It’s astonishing! Yet, perhaps underwhelming and perhaps makes us think that we are better than the research makes out? Blogs shouldn’t be lengthy and it would take me days to discuss this further. I want to share a bitesize chunk to encourage people to think outside the box.
If you want to watch the webinar Paul recorded for Trust me-ED where he elaborates on this topic, you can click here:
So, this blog is written for two groups of people. 1) Physiotherapists that want to feel confident in their knowledge and ability to deliver modern evidence based care and 2) patients that need support, care and attention for the high proportion of diseases that are diagnosed every year and the medical procedures that they undergo.
Firstly, I feel it is important to explain some of the issues that the physiotherapy profession is tackling.
Society is changing, populations are increasing, people are living longer, with that comes increases in disease, age related health conditions, strain on food stocks, the environment the list goes on depending on how broadly you look at the relationships. As such current medical services are struggling under the increasing pressure. One such issue is the current model that the medical system continues to practice under. The biomedical model has dominated for hundreds of years (this is not a rant about the biomedical model). Viewing the body as machine has no doubt had its effect on increasing life and helping illness. Yet with all models it has many limitations. So, this is to say that the biopsychosocial model also has its limitations, yet it fits the current shift in understanding of many clinicians (and the public) that see the changing landscape.
Physiotherapy has always had a close affinity with the medical system (Nicholls., 2018). The physiotherapy profession essentially adopted a teaching model that was similar to medical doctors and surgeons. This model is fundamentally lacking in several areas when it comes to what physiotherapists class themselves as. I think the majority of physiotherapists would agree that we are movement specialists. Now depending on how narrow or broadly you want to think about this, it shows a huge gap in what we understand movement to be. Let me offer a few thoughts:
- If we consider the interaction with a patient between a physiotherapist, doctor and a surgeon. In terms of time, a patient tends to spend 10-15 minutes with a doctor and when it comes to surgeons well most people are asleep. Physiotherapists on the other hand have much longer. However, we work with a very different patient population. Yes, we might see the same patient that the doctor or surgeon has seen, yet, this is a very different person – The patient has time, is awake, perhaps distressed, experiencing pain, perhaps frustrated, wants someone to listen and likely has many many questions that the surgeon or doctor hasn’t or even can’t answer. I am comfortable with the idea that humanistically physiotherapists can offer more than a doctor or a surgeon. Perhaps on paper we don’t have M.D. after our names or all the other letters, but when it comes to connecting with people, that’s irrelevant. Patients are often left standing on a cliff edge wondering what they must or must not do? What they should or shouldn’t do? What the can or can’t do? We need to take this opportunity to show how much we can offer, to inform the public that the white coat doesn’t have all the answers.
- I keep saying that we are so much more than just the clinician that pushes, pulls, prods, pokes. I have my reservations with these things. Perhaps physiotherapists don’t realize they are so much more. Actually, scrap that this is what society expects from us! If we are truly the movement specialists that we claim to be, then we should be aware of the movement at a quantum level, the movement of energy and nutrients between cells, the movement of cells around the body, during inflammation, healing and ageing. We should also be aware of movement at a social level, a vocational level and a political level i.e how our interactions with the environment, work colleagues, managers etc have an impact on the physical and mental health of our patients. Physiotherapy needs to evolve and step forward to take up the mantle of responsibility and say, “I will inform and educate the patient, their family, the friend, the surgeon, the trainer, the employer, the nurse, the doctor, the case manager”
- Frustratingly, physiotherapists continued to be trained in such a way that mirrors the medic. The metaphor body as machine is deeply rooted into the physio teaching curriculum. A recent reflection helped me to understand that the biomedical model was not necessarily the wrong choice for our teaching. My issue is we continue to push these ridiculous notions that we can realign joints or mobilize tissue or use machines to expedite a process that the body does by itself. We then proclaim that this is important for healing and movement. This low hanging fruit, a prehistoric belief, is deceptive and devalues the resilience and adaptability of the body. It also instills concern and vulnerability in people. We are creating dependency and concurrently this increases pressure on medical services. There is no doubt that we are social beings and we crave touch and compassion. This is where manual therapy is most powerful. Yes, there are plenty of reflexogenic and mechanoreceptive effects that come with hands on and that’s great, but that’s where the buck stops. We need to shift our focus away from relying on tools to do our job and understand and then utilise the philosophical underpinnings of physiotherapy. That way (I believe) we will truly be able to harness an understanding of our profession.
How can Physiotherapy help the public?
Oh man! The opportunities are unbelievable! Let’s pick apart a few areas where we are hugely influential. Before I continue, I want to stress how important the biomedical model has been in our understanding of the body. I previously highlighted that is has been a big player in our understanding of the body. To add to that it gives us an edge over most other health professionals who do a 6-month course or become part of a profession that has focused its entire teaching on a specific body part. I am asking that we refine that knowledge, we ditch the nonsense and really focus on what’s important in the biomedical model encompassing it with a biopsychosocial approach.
So, how can physiotherapy help the public. There are many areas, but for the purpose of this blog I will look at five:
This is probably the most significant area that physiotherapy appears to have the greatest attraction and impact. There has been extensive research in understanding the resilience, adaptability and capacity of musculoskeletal tissue (meat, gristle, bone). One such paper that has changed our understanding is by Khan & Scott, (2009). Mechanotransduction is apparent throughout our cells. The ability of our cells to communicate with each other when stress or load is applied upon them separates us from the body as machine metaphor.
As the image above implies if we can identify stressor, and determine if the stressor is causing too much pressure on the individual then it really can be as simple as 1) modifying the stressor or 2) modifying the response to the stressor. It means that in a lot of cases we don’t need the injection or the surgical intervention to replace something. It means that as physio’s we need to be informing patients that the quick fix doesn’t exist, it takes time for things to heal, and with ageing it unfortunately takes longer for things to heal. Where we fall down is we don’t inform the employer, the family member, the surgeon and often we don’t inform the patient! If we are to claim we are movement specialists then movement is about exchanging and sharing information with other people/professionals that are involved with the patient in one way or another.
I don’t need to highlight the vast ocean of research that is out there around pain management. We understand that pain and tissue damage are exclusive, that plastic changes occur in nerves to make our nervous system more (or less) sensitive, the effect that language, behavior, beliefs and expectations can have on the nervous system. We know we can desensitize, retrain, use visual illusion, placebo etc to modulate pain. We know the benefits that activity can have on the endogenous system to modulate pain. We are understanding more about the importance of sleep, stress and mental health on persistent pain. Most importantly we are able to provide hope to the millions of people who live with persistent pain every day. I emphasize the need for clinicians to constantly question your biases and reflect on your delivery of the intervention and exchange in information. If you don’t you are very likely way off the mark!
Osteoarthritis (OA) is a real problem for a lot of people, it is the most common joint disease particularly in the over 60s. It is one of the musculoskeletal disorders where there is ongoing tissue irritation and associated pain. It’s linked with age, being overweight and muscle weakness, but also with individuals that have sustained injury so the onset can occur in the younger population (Pedersen & Saltin, 2015). Physical activity, aerobic and resistance training has been shown to have significant positive effects on OA. Resistance training has been shown to have similar anti-inflammatory effects to that of NSAIDS like Ibuprofen and even Acupuncture. Aerobic exercise has been shown to have similar effects to a corticosteroid injection!! (Pedersen & Saltin, 2015)
N.B. It’s important to highlight that with research studies if a trend occurs in positive responders that will be the focus of the results/discussion. There will always be outliers in these studies and as such we need to make sure that our approach is directed towards individualized care.
As such questions are arising about an Osteoarthritis subgroup classed as a neuropathic pain disorder (Thakur, Dickenson, & Baron, 2014). This may help the increasing numbers of individuals that live with significant knee pain associated with the disease and may not respond in the same way. Furthermore, it is important to note that there may be other factors that are involved in person’s pain and disability associated with the disease.
Cancer is another area that physiotherapy can play such an important role. There are a high number of studies published to show the significant effect that physiotherapy and exercise can have in several areas of cancer management. This includes prevention of cancer recurrence (Lemanne, Cassileth, & Gubili, 2013) during chemotherapy (Courneya et al., 2013), post-operative pain and complications (Glare et al., 2014), expectations (Koller et al., 2000), re-enablement back to exercise and re-integration into society (Spence, Heesch, & Brown, 2010). Having had the experience of my partner living with cancer this year, there was much discussion around exercise as part of her aftercare. This will be discussed further in a future blog.
Physiotherapy has a huge impact in pelvic health. Although more common in women there is a percentage of men that have pelvic health related issues. Perhaps there are more than we realise due to the stubborn nature of men not talking about their pelvic health issues. One paper I want to highlight in this section is the POPPY trial published in the Lancet. The POPPY trial consisted of an individualized pelvic floor muscle training program for women with pelvic organ prolapse. Participants in the trial were invited to attend five one-to-one appointments for pelvic floor muscle training over a 16-week period. They were taught by a trained physiotherapist about pelvic floor, the pelvis and other parts of anatomy and provided with a home exercise program. At 6 and 12 months, there was a significant reduction in prolapse symptoms who underwent pelvic floor training. The importance of this trial was to show that with regular exercise and training symptoms could improve. Once again there is no quick fix, that time and regular practice provided the best outcomes (Hagen et al., 2014). I have a guest post coming soon!
That concludes my rather large post about physiotherapy. There are many other areas that physiotherapy can have significant impacts on public health i.e. in neurological care and respiratory care. All I can say is that this is such an exciting time to be a physiotherapist. We have so much to offer, more than we actually realise. Through broadening our clinical scope, improving our clinical reasoning and critical thinking skills we have the ability to be an independent specialist, advisor and valued clinician in promoting public health. We can encourage and support people to take ownership of their health with less responsibility placed on a medical system that doesn’t always provide all the answers and doesn’t always meet our expectations.
Of course your comments are always welcome.
Thanks for having a read.
If you want to watch the webinar Paul recorded for Trust me-ED where he elaborates on this topic, you can click here:
Courneya, K. S., McKenzie, D. C., Mackey, J. R., Gelmon, K., Friedenreich, C. M., Yasui, Y., … Segal, R. J. (2013). Effects of exercise dose and type during breast cancer chemotherapy: Multicenter randomized trial. Journal of the National Cancer Institute, 105(23), 1821–1832. https://doi.org/10.1093/jnci/djt297
Glare, P. A., Davies, P. S., Finlay, E., Gulati, A., Lemanne, D., Moryl, N., … Syrjala, K. L. (2014). Pain in cancer survivors. Journal of Clinical Oncology, 32(16), 1739–1747. https://doi.org/10.1200/JCO.2013.52.4629
Hagen, S., Stark, D., Glazener, C., Dickson, S., Barry, S., Elders, A., … Wilson, D. (2014). Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): a multicentre randomised controlled trial. The Lancet, 383(9919), 796–806. https://doi.org/10.1016/S0140-6736(13)61977-7
Khan, K. M., & Scott, A. (2009). Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. British Journal of Sports Medicine, 43(4), 247–252. https://doi.org/10.1136/bjsm.2008.054239
Koller, M., Lorenz, W., Wagner, K., Keil, A., Trott, D., Engenhart-Cabillic, R., & Nies, C. (2000). Expectations and quality of life of cancer patients undergoing radiotherapy. Journal of the Royal Society of Medicine, 93(12), 621–8. https://doi.org/10.1177/014107680009301205
Lemanne, D., Cassileth, B., & Gubili, J. (2013). The Role of Physical Activity in Cancer Prevention, Treatment, Recovery, and Survivorship. Oncology-New York, 27(6), 580–585.
Nicholls, D. A. (2018). The End of Physiotherapy. Routledge Advances in Health and Social Policy. Abingdon, Oxon. ISBN 9781138673557
Pedersen, B. K., & Saltin, B. (2015). Exercise as medicine – Evidence for prescribing exercise as therapy in 26 different chronic diseases. Scandinavian Journal of Medicine and Science in Sports, 25. https://doi.org/10.1111/sms.12581
Spence, R. R., Heesch, K., & Brown, W. J. (2010). Exercise and cancer rehabilitation: A systematic Review. Cancer Treatment Reviews, 36(2), 185–194. https://doi.org/10.1088/0031-9120/36/6/301
Thakur, M., Dickenson, A. H., & Baron, R. (2014). Osteoarthritis pain: nociceptive or neuropathic? Nature Reviews. Rheumatology, 10(6), 374–80. https://doi.org/10.1038/nrrheum.2014.47