Now before I get a swathe of complaints from my Physiotherapist friends I am including Sports Therapy in this sweeping statement too! With Sports Therapy focusing on the musculo-skeletal aspect of Physiotherapy, Sports Therapists like myself are just as culpable.
So why would any Sports Therapist or Physiotherapist question the underlying fabric of the entire subject? I’ve always been the one who asked why. I think it started as an annoying 5 year old. Sentences either ended with “Why?” or started with “I want!” 35 years later and here we are. I don’t question these things lightly. I’ve always been a good boy and don’t like to stir things up… but this post has been brewing for a while.
What’s The Problem With Traditional Physiotherapy?
The problem I see having treated people for 12 years is that the traditional Physiotherapy (and Sports Therapy!) model takes no account of the individual. It’s not personal. Being given a sheet with a bunch of exercises on and being told to go fix yourself is hardly inspiring. It’s simply not addressing the client or patient as a person, just another statistic. For example reading literature which claims “after 6 weeks of strength training 50% of patients reported a 40% improvement in symptoms”. To me this is a rubbish outcome! This would actually be one of the better exercises as well.
Pain is a complex beast as we discussed in our blog 50 Shades Of Pain. It has many different sources as our friends from the NOI Group frequently remind us. A large part of people’s pain comes from their beliefs. If you think something will hurt forever then it probably will. At least until you are shown a different way to change that belief. Fear plays a huge part of our pain experience. If we’re fearful of making things worse we tense up expecting pain… and guess what, that makes the pain worse!
Stress is also a big player in our pain experience. The more stressed we are the more pain we feel. Very briefly to get technical our pain receptor proteins are more porous to the pain chemicals in our blood when we are stressed. Likewise when we are ill and run down. Have you ever considered why everything hurts when you have a cold or flu?
Symptom Driven Physiotherapy
That’s just on a personal and psychological level where the traditional model is failing. The next aspect of where the old physiotherapy model is failing is just looking at the symptoms. The Physiotherapy text books are full of conditions with scary sounding names – what do you think that does to peoples fears and anxieties?! Most of them don’t really exist. They’re just labels to try to explain a myriad of conditions that can have different causes in different people.
Surely it’s better not to worry too much what it is called but more focus as what we as therapist and client can do to sort the problem out. Traditionally each condition is then focused on to “retrain” the area where you feel the pain. But is this where the problem lies?
I fully understand the reasoning behind being symptom driven. It is after all human nature. I have a pain here, there must be something wrong with the bit that hurts. I still even do it myself. If my back aches after a long day fixing people I poke it. Does it help? Not often!
There is an increasing body of evidence to give the clinician the confidence to look away from the symptom to the areas that are affecting the symptom to give a better long term solution. Our friends at Anatomy Trains have created a fabulous framework which explains the interconnections of the muscles and fascia of the human body. The structures involved in your pain maybe very close, they maybe completely the other end of the body. But all aspects of how we hold ourselves will feed into the pain we feel. We are after all one big system, otherwise bits would keep falling off!
So Is All Physiotherapy Wrong?
Of course not. As someone who’s been there and done that I fully respect all traditional facets of physiotherapy and sports therapy. It is my intention here to question to strive for better treatment and show potential clients that there is hope – even when they have been otherwise. For fellow therapists reading this post my plea is to continue your learning long beyond your initial training. There is so much out there that we weren’t told when qualifying that quite simply gives you way better results than what you were taught.
I think that traditional rehab principles work excellently for new injuries. There are ever improving recovery time from major injuries and operations such as ACL reconstruction that just wouldn’t have been possible previously. Obviously the surgery has improved but so to have the Physiotherapy and recovery programmes. That said it’s in the recovery phase after about 6 weeks that we then need to also consider the impact on the whole body.
For example it you’re recently had an ACL reconstruction, or less severely a ankle sprain. You will limp. As much as I tell you “pain is not damage” it’s still going to happen. This changes our movement patterns very quickly. Then, when the local tissues are healed, the movement pattern remains and the perpetuates a painful movement pattern. This is where a whole body approach needs to be allied to a more localised traditional physiotherapy model. There also needs to be consideration of the person’s emotional response to the injury and ensure their beliefs are positive and any fears quickly addressed.
Is The Pain The Problem?
As we mentioned earlier we naturally go to the pain. But dysfunction doesn’t always lead to pain. This is why I’m not a massive fan of costly MRI scanning – except in certain very specific cases in which case it’s a fantastic tool. But I feel as clinicians we rely on it too much. If you look hard enough you will always find something that isn’t quite right. And there’s no guarantee that what you find is “the” one thing that is causing your pain.
You need consider has anything actually changed to give me this increased level of pain? Was there a specific incident when this started to hurt. Maybe a gorilla tried to rip your arm off! Or you heroically rescued a baby from an onrushing car. Then yes you may have damaged something. But if not, or if you did do something and it was a long time ago, we can usually fix these problems with some simple bio-mechanical tricks to get you working in the right pattern again.
If works the other way too. You can actually have a recognised condition and have absolutely no pain at all. We regularly see this with disc problems. You can have a minor disc bulge with major pain or conversely a massive disc bulge compressing on the nerve root with little or no pain. This is backed up by this fabulous piece of research. Which if you scroll down until you see a chart shows you what “conditions” an MRI scanner found in people with no symptoms!
Why Am I Ranting Now?
Well firstly I like a good rant! Secondly I’m just back from a course. Which is always a dangerous time! A fantastic course (the first of 3 weeks this year) with the fantastic world renowned Physiotherapist LJ Lee. LJ is quite simply on the money when putting it all together. Using a truly inspiring amount of anatomy knowledge to find the true cause behind the problem.
She quite reasonably asks is there any evidence for evidence based practice? What would you prefer as a client? Something that improves symptoms by 40% in 50% of cases and takes 6 weeks that has been proved in a randomised controlled trial (RCT). Or something that hasn’t been proved in an RCT, that works frequently in clinical practice, and reduces your individual symptoms by 100%?
The Verdict On Traditional Physiotherapy
So I’m very much looking forward to implementing even more whole body assessments and treatments to help fix people in ways that people were least expecting. So long as it works and it’s carried out with the appropriate safety measures in place it’s all about the outcome for the individual. You can choose to see a Physiotherapist who hands you some exercises and rubs you with some ultrasound or you can choose a Physio or Sports Therapist who will use every ounce of their knowledge and technical ability to find the right solution for you. It’s your choice.