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Family Feud: Physiotherapy Wars

14 October, 2017

There’s a bit of disquiet in our physiotherapy profession. I’ve been a Physio for 40 years and I’ve never seen anything like it. But I suppose if there had been anything like it years ago, we wouldn’t have necessarily known about it – but thanks to social media, the family tiff is there for all to see. All the dirty laundry is being chucked in the street, there’s cursing and swearing and it’s starting to get ugly. I thought I’d write about it in case anyone out there who’d like to get some treatment for their ailments is worried that as a profession we are spending much of our time navel-gazing and not paying attention to our patients.

Mind you lots of the angst revolves around a pretty good principle – that what we do in our clinical practice should be evidence-based. And the carry-on has been from those who believe some physios……maybe many physios, are not responding to the evidence in the literature and abandoning the old comfy go-to treatments that actually have no evidence that they do anything or if patients do respond to techniques such as manual therapy, it might be for a different reason to the ones we were taught 40 years ago.

The bone of contention is that the evidence is weak or non-existent in some aspects of traditional musculo-skeletal physiotherapy treatments such as:

  • manual physiotherapy treatments (mobilising and manipulating joints)
  • strict posture alignment philosophies
  • using machines such as therapeutic ultrasound (not real-time ultrasound which is use to view muscle contractions or like we use to check bladder emptying) and a few other types of machines
  • dry needling treatments
  • and courses promoting very complicated techniques with fancy names.

There has been a kind of revolution in the pain science area – and it only took about 50 years to build momentum. The philosophy when following Pain Science research is that once all red flags have been looked for and eliminated as a cause for the pain:

  • that more hands-off strategies have better value for solving a patient’s pain
  • that promoting self-efficacy in our patients has better long-term outcomes
  • promoting confidence of the patients in their bodies, (not fear that something might fall apart without using certain postures, alignments, belts or 5 Step Programme with a fancy-pants name) has better efficacy
  • empowering patients with knowledge about chronic pain to deal with potentially inevitable flares and recurrences in the future
  • that if some hands-on is required that it may work on a different principle to what we were taught many years ago.

The argument is that whilst physiotherapy as a conservative strategy causes no harm, it can be costly for a patient if they are encouraged to come twice weekly for a treatment to keep the ailment ‘under control’. Or it makes the patient feel broken when fear-mongering language is used to describe their condition. Or that the explanation for the pain/condition sounds so complex that the patient can’t self-manage it – it requires ongoing long-term assistance from the physio.

We are very lucky in continence and women’s health because it is one of the well researched areas in physiotherapy with good evidence about pelvic floor muscles training and other conservative life-style strategies improving the outcomes for incontinence and prolapse management. And to be honest I haven’t a lot of experience with this mentality of over-servicing and using machines (called bells and whistles) because certainly in the area of women’s health and continence promotion, this is mostly based on a longer initial appointment which has time for an assessment, comprehensive education of the bladder, bowel, pelvic floor muscles, teaching strategies for self-management of their bladder and bowel condition, pain management as necessary, an extensive home programme; with review once at a month post the first appointment and then often a follow-up at three months and that’s it.

Of course with persistent pain problems it may be necessary to see patients more often than a 3 month appointment. Once I started employing more physios to help with the workload and they had musculo-skeletal experience and we started seeing musculo-skeletal patients, the philosophy of Explain Pain is one I have encouraged at our practice and the girls are very good at helping patients with treatment that embraces education, some hands-on, a programme of exercise and ongoing self-management.

 

Books from NOI Group for understanding pain.Explain Pain and The Protectometer

I know I have had patients over the years who have been seeing a chiropractor and paid in advance for 2 treatments a week for three to six months (???) and I have been shocked at that concept and wondered about the ethics of it – what if the patient gets better after the second visit? But I suppose because of the ruckus in social media there must be some physios who are using treatment techniques that are not evidence-based; who are putting people on machines – maybe to satisfy the patients’ view that they have always had ultrasound/ short wave diathermy or whatever and they need it today; and who are using overly-complex posture/alignment theories to make the patient fearful about how to sit and move.

The problem as I see it is that social media has provided a platform for physios who have lost patience with the slow uptake of the newer approach on managing pain by many musculo-skeletal physios and they are now using shock tactics to blast the profession out of the dark ages and into reading the evidence, acting on the evidence and changing their beliefs and practises. There has been some fruity language and disparaging comments about these practises (not the noun practices) and for many physios this is offensive – and can be seen as running down our profession. But I can see their point of view  and let’s face it – it can only be good for the longevity of our profession to be seen to be completely evidence-based and not just sticking with old-age practises because they’ve always just done it that way.

Being around for 40 years as a physio I have seen a lot change from what I was taught when I was in my black and white checked gingham mini (very mini) massage/prac outfit. (Unfortunately in my day at Uni we didn’t take photos of every moment in our lives and so despite searching and searching, there is NO photo of this little number we all dressed up in to do our pracs! If anyone from my vintage has said photo I would really love to see one.) I have been very determined over the years of working that I remain relevant and up-to-date and have attended the majority of conferences and workshops that have been available in Continence and Women’s Health and pain management over the years. This has meant that I have attended 3 Explain Pain courses over the years and every time there is more evidence and explanations that really kibosh many of the techniques and treatments I was taught 40 years ago.

However the biggest revolution in my continuing education has been thanks to social media, which I embraced back in 2011. My daughter who is in Public Relations taught me about Twitter and Facebook from a professional point of view (not from a Kardashian point of view) and it has completely revolutionised the amount of reading I do (evidence-based articles, patient case studies, other professions view on things – the Urologists are very active on Twitter). The beauty of Facebook and Twitter is they provide an opportunity to experience and participate in a kind of debating without hearing the eloquent voices and the torrid debating skills. Sometimes the debates deteriorate into a schemozzle and hate-fest, but the debates are mostly informative and do change your thinking.

I admit to regularly changing my narrative and handouts in clinic after a good stoush on Facebook – I go back and forensically change any words that may strike the fear of God into a patient’s mind – and I am reviewing my books to do the same things. This keeps me feeling comfortable working still at 61 – I don’t want to just go into work to go through the motions and top up the super for a comfortable retirement. I want to be offering our patients the best treatment there is based on the evidence and the best treatment there is to make them feel like they are in control and have strategies to continue for the rest of their lives. Yes they may pop in for a review yearly for a top-up of more confidence-building information or to trouble-shoot a snag they have hit. But as physios we should make them feel like they can do this and they don’t need twice weekly hands on/machines on from us.

What is useful to do on a regular basis is exercise!

   

My main goal in providing a place that provides opportunities for exercise – dance, pilates, yoga, barre and our new combination class (aerobics plus pilates)- is to progress patients onto exercise and movement for pleasure, for dementia prevention, for strength training and for pain management. Getting patients to love exercise – to see exercise and movement as a life-long strategy for good health and a happy life and keep them away from the physio is actually my goal.

      

But like most families, I am sure we will resolve this little hiccup. We shouldn’t be afraid to embrace Change because change keeps us on our toes and keeps us alive and vibrant – not stuck in the mud and reminiscing about the good old days back in the fifties. Change makes us relevant and not redundant. It makes us feel easier when we sleep at night knowing we are telling the patients the correct science and not winging it; it makes us make the patients feel empowered and independent, but with the knowledge they can call on us at any time for a review and we’re not going to use it as an opportunity to string it out for weeks / months.

Postscript:

As I had hoped the first photo has emerged of PART of our prac outfit (Thanks to Anne who sent it to me). Yes it’s the black and white check bikini top on the hanger – the bottom part has vanished. It’s even more skimpy than I remember! I would be so excited (as would others in our cohort) if someone had a photo of one of us modelling it. Please send to sue@suecroftphysiotherapist.com.au

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12 Comments
  1. Well said Sue

  2. Helen Fisher permalink

    You are amazing sue!! Thank you for your stories, your wisdom, and your genuine concern for the human race!!
    Hel xx

  3. Abby Aitchison permalink

    Interesting read Sue, and I mostly agree. What I would like to know from you is whether you distinguish between the “twice-weekly manual therapy for life” and the “carefully used manual therapy which is used amongst careful language and exercise prescription with the view to discharge after a few sessions”. I don’t even think David Butler himself would completely write off manual therapy. One thing is for sure, I am looking forward to the APA conference next week!

    • Hi Abby I treat pelvic floor dysfunction – I am reporting and observing a lot of loud noise about musculoskeletal physio- I think I made it clear that the musc physios that are at my practice do pretty much what you are asking about- so of course what you are describing is completely different to what the noise is about. Yes I hope you let me know what you hear at the APA conference- I have elected to go to CFA (Continence Foundation of Australia) National conference instead.

  4. Gay Small permalink

    Excellent blog Sue. I remember my daughter in the black and white skimpy outfit but, alas, no photos. I think that put her off gingham for life.

  5. Anon permalink

    Really appreciated hearing your opinion in this article. Working in Oz I’ve found two things that haven’t helped physios using evidence based medicine approaches for pain relief.
    1. The pain management strategy with the Aged Care Funding Instrument, where an aged care facility receives funding if a resident requires 4 times weekly treatments (massage/ TENS) of 20 mins for the rest of their life to manage their pain.
    2. Commission based incentives in private practice: I was once told by a physio practice that I was required to see each client on average 10 times for a condition (even if they were better) and was given a warning for “underservicing”

    • Well both those examples are disturbing – the choice you have working in the private practice is to choose to say that’s unethical and if you are forced into doing it then look for another job. The other example needs some sort of investigation if it’s accurate – it’s an absolute disgrace.

      • Anon permalink

        The ACFI funding instrument had been that way for pain management for years. If a allied health professional gives a 20min massage or tens machine or other passive modality, 4 times a week to a resident for pain management it is equal to an extra 20-40 dollars a day in funding from the government to the aged care facility. Where is the evidence based medicine approach in that?

  6. That is disturbing information. And I think it deserves more exposure and investigation. Thanks for letting me know

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