Physio Crisis

Musculoskeletal physiotherapy I think is going through an identity crisis. I don’t mean the kind that makes it dye its hair, wear leather trousers, or tries to impress other professions half its age. Rather I think musculoskeletal physiotherapy is struggling to find its place and purpose in healthcare system and so is trying to do new things and is loosing sight of what its real role should be.

The physiotherapy profession has produced a huge amount of research in the last 20 years in an attempt to demonstrate its worth and effectiveness. However, a lot of it highlights that physiotherapy has little to no significant effect above placebos, natural history, or regression to the mean, and people are beginning to notice (ref).

This has created a lot of debate within physio with many advocates fighting hard for their cherished treatments, and others like myself questioning their worth. Some have talked about this crisis with blogs telling us how ‘physio will eat itself’ and books called ‘The End of Physiotherapy’ both of which I urge you to read.

However, physiotherapy continues to desperately search for evidence to prove it worth and earn its place within healthcare, with debates and arguments raging on about what are the best treatments for this pathology or that problem. But has physiotherapy and many within it (including myself) focused its efforts and energy in the wrong place? Has physiotherapy lost sight of what it could be preventing rather than what it can treat, and is it in need of a drastic shift in its identity of what it does and how it does it as a profession?

Treat or Prevent?

The vast majority of physiotherapy research and physios themselves invest a lot of their time, energy and effort into diagnosing and treating pathology, disease, and disability. This is clearly important and should be continued, but what about the other side of the coin? What about our efforts in the prevention of pathology, disease, and disability?

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Does the physiotherapy profession invest as much time, energy, and effort trying to prevent disease, and disability as it does trying to treat it? Does the physiotherapy profession place as much importance and relevance on the promotion of health and wellness as it does on the treatment of sickness and illness?

Simply put… HELL NO!!!

Most, if not all of physiotherapy’s training, research, practice, and effort is focused on the reduction of pain and the improvement of function in those WITH disease or pathology. Very little, if any time, attention, or resources are given to ideas, methods or strategies to prevent or reduce the prevalence of disease and pathology.

Simply put… Physiotherapy is a reactive profession, not a proactive one!

And this applies not just to physiotherapy but to all of healthcare, with the National Health Service in the UK better described as the National Sick Service as it does very little to help educate, influence or change the nations behaviour to help improve its health.

Now I am not just trying to be hyper-critical or overly negative here, and I know there are some within the NHS and some physios who do work proactively in some health promotion roles, but they are in the minority, and they are not well supported, funded, seen or heard. This, in my opinion, needs to change drastically.

Currently, physiotherapy along with many other healthcare sickcare professions are bogged down in the endless ever-increasing pressures of treating pain, pathology, disease, and disability to do much about the prevention or reduction of them. This is a classic vicious cycle if there ever was one, and it’s one that is leading us into a right royal shitstorm.

Tsunami of Disease

With an ever-increasing ageing population that is doing less and less physical activity, with poorer and poorer lifestyle behaviours, declining health, and greater co-morbidities, are inevitable and our healthcare system is facing a tsunami of chronic illnesses and disabilities that it can never hope to manage and is going to be swamped very soon.

It is estimated that by 2050 the UK’s population will have expanded by another 10 million people with a significant increase in those over the age of 60 (ref). This increasing elderly population will have far higher rates of chronic long lasting morbidities such as obesity, diabetes, and cardiovascular disease, that will require long term treatments and support.

It is estimated that in just 10 years over half of the UKs population will be clinically obese and the associated health issues of this alone will cost the NHS a staggering £25 billion (ref). Thats more than all the budgets for research into cardiovascular disease, cancer, and diabetes combined (ref).

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There is no way our healthcare or financial systems can cope with this, and if they only keep focusing on treating rather than preventing disease it will soon find itself overrun by the chronically ill and disabled needing constant care. Therefore, more time, effort, resources and opportunities need to be placed as a priority into the prevention of disease and illness, and I think the physiotherapy profession is in a prime position to help here.

However, as I said the physiotherapy profession is very much focused on only the diagnosis and treatment of disease and illness rather than the promotion of health and wellness. And if you don’t believe me just take a look at its recent training, career structure, and its position within health care and society in general, especially now with it emphasis on first contact, extended scope, and advanced practitioners who essentially are cheaper, poorly trained, and less skilled GPs and specialist registrars!

Physio Training

Currently, in most physiotherapy training very little time is spent on health and wellness promotion and advocacy. This needs to change! More emphasis, time, and energy are needed to train and enthuse current and future physios on the importance of health promotion and advocacy in all those they see.

physios need more support, encouragement, training and skills in how to communicate, motivate and encourage behavioural change in all those they see with some minor aches and pains or injury, knowing how to overcome barriers and obstacles to healthy lifestyles, far more than they need to know what settings to use on an ultrasound machine, where to place an acupuncture needle, or how to go a grade 3 mobilisation on L4/5.

Physio Careers

Most if not all musculoskeletal physiotherapy career pathways are focused on and dedicated towards extended or advanced skills in diagnosis and treatment, there are virtually no career options for those physios who want to focus on health and wellness promotion. This needs to change!

For an MSK physiotherapist to progress their career they have to do further training in either manual therapy, acupuncture, dry needling, diagnostic imaging, injections, blood tests, even prescribing medications. For an MSK physio to be seen as advanced, enhanced, or specialised they have to twist, contort, and turn themselves into some bastardised version of a doctor, registrar, or radiologist. I know this because I have done it myself, and I don’t like it.

And this is not to be disparaging, negative or critical of all the ESPs, APPs, or FCPs or whatever you want to call them, as again I am one, and I know there are some excellent ones doing some excellent work. But where are the Extended Scope Physios in health promotion?

Where are the Advanced Physio Practitioners in exercise and activity prescription? Where are the First Contact Physios in schools educating children on the importance of healthy lifestyles?

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The MSK physiotherapy profession needs to take a long hard look at its training and career structure, and stop placing as much emphasis and credence on skills that only diagnose or treat those with pain and pathology. It needs to start to place more emphasis, training, focus on skills and attributes that promote health and wellness. Simply put we need more physios enthusiastic and striving to become health and wellness advocates, not junior doctors.

Physio in society

Currently, most if not all MSK physiotherapy is positioned in reactive roles, treating people with problems sent to them. It is also still very much seen as a junior, inferior, even subservient profession to other medical professions. This needs to change!

More MSK physiotherapy needs to position itself outside of hospitals and medical centres, and into gyms, health centres, and even schools. Health promotion and advocacy should begin from a young age and physiotherapy should be lobbying governments and pressuring policymakers about the benefits of placing physiotherapists and health and wellness teachers into the national curriculum.

MSK physiotherapy wants to try and position itself as being seen as a profession that helps promote health and wellness as much as it helps treat disease and illness. Our leaders and societies need to do more to push this forward using lobbying and other political pressure.

With the World Congress of Physiotherapy currently on in Geneva this weekend, it is encouraging to see the odd slide and comment about this already, but more needs to be done and I do wonder how much of this is talk and how much action will come of it?

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Summary

As I mentioned at the beginning, the MSK physiotherapy profession needs a drastic shift in its identity and thinking of what it is, what it does, and where its role and worth lies. Is it in the diagnosing and treatment of pain and pathology, which hasn’t been shown to be that great or effective, or is it more in the prevention and reduction of pain and pathology through the promotion and advocacy of health and wellness?

Obviously, the answer is both! But at the moment MSK physiotherapy is very much focused on the treating more than the preventing, it’s more reactive than proactive, and if it wants to survive and be taken seriously as a ‘health care’ profession this needs to change!

As always thank for reading

Adam

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13 COMMENTS

  1. Maybe health promotion in the field of mindfulness would be a good start. We’re still too wrapped up in assessing the body instead of the effect of training the brain in its relationship to the body

  2. Spot on, as usual, Adam: wellness and prevention should be the next BIG THING. Two comments: 1. In the US fee for service system, it is difficult to get paid for wellness and prevention sevices today, BUT 2. Employers are desperate to keep their aging skilled workforce working and employers know that they aren’t getting value out of today’s reactive healthcare.

    Thanks again for your thoughtful insights.

    • Great read and agree 100%! I’m a PT in the US, worked on inpatient rehab for my first 6 years of practice. The vast majority of my patients had had a major event related to lifestyle choices including diet and lack of activity. I became burnt out on treating people that I felt were doomed, people generally struggle to change lifestyle habits even before they have the stroke for example. I had actually thought about leaving the field and going to sell motor homes! I decided to give outpatient a try. One of my very first patients was a 730lb gentleman sent to our clinic for back pain. My first thought was we were not going to be doing anything for this guy is we didn’t address lifestyle issues. Fast forward 3 years and we have been able to successfully get many patients off of diabetes medication, blood pressure medication, increased activity levels, weight loss, improved sleep patterns and nutrition. Insurance likes to pay for pain and improving function so we simply manage these issues and document the improvements while simultaneously addressing the other issues via a holistic program. It has certainly been an uphill battle, with the majority of resistance coming from within the profession; “you can’t discuss nutrition with patients”, “you can’t discuss stress with patients”, “you can’t bill for wellness”, the list goes on and on. Lifestyle factors such as obesity and inactivity go hand in hand with pain, so bill for addressing the pain but provide the lifestyle change in conjunction. We guide many of our patients through a workbook called Wellness 360 which incorporates behavioral change psychology, motivational tactics, etc, to help our clinicians methodically address these issues with patients, help patients set goals and develop a life vision worth putting in the necessary work to make the changes.

  3. You have made many points that are worth fleshing out further. Regardless, the profession of physiotherapy is much less a coherent organization of theory than it is a conglomeration of seperate interests barely held together. Case in point, the use of the descriptor, “MSK” to specify something in the physiotherapy profession is a huge reach. Perhaps if there was more unity in the profession, there would be less need to create false competencies in areas where there may be little to none. Physio wants claim expertise in some of these areas as if such reductive thinking will lead to success (and self-confidence), but this has never been demonstrated.

    There us no such thing as an “MSK physiotherapist”. That is a myth generated by an insecure profession struggling with its identity crisis, never resolved. Until physios stop needing to divide themselves professionally into divisions, little reformation is possible.

  4. I couldn’t agree more but as was pointed out in the post on your site about physiotherapists not having even the basic knowledge of the current minimum guidelines on exercise prescription how can we promote a prevention culture? We all know that the general public have a ‘fix me’ mentality and are unwilling to even consider investing in their own health and that unwillingness is seen within our own profession, unfit, overweight physiotherapists. Hardly a good example.

    Yes there are a few who do try and promote health, but do they have the resources to provide this? On the whole I’d say no. I treat (?) people with genetically inherited diseases that affect muscles and nerves but every patient who comes through the clinic is advised on exercise and health but can I use the hospital gym for a group session? No.

    Prevention is key but that requires a shift in the way physiotherapists are educated and position themselves in the health service but more importantly it requires a paradigm shift the general population attitude to taking responsibility for their own health. Sadly a big ask in todays society

  5. People come to a physiotherapist when they want to fix a problem.
    To prevent that problem in the first place, the proactive physiotherapist has to come before.
    And that could be done through educating people. Nowadays there is an abundance of media channels through which the education could be done efficiently.
    Yet, do the “doctors” have the time and the will to do that?
    I see the crisis. Leaving the white robe in the office could be a first step.

  6. Adam, your assessment hits the mark:

    “Currently, most if not all MSK physiotherapy career pathways are focused on and dedicated towards extended or advanced skills in diagnosis and treatment, there are virtually no career options for those physios who want to focus on health and wellness promotion. This needs to change!”

    “For an MSK physiotherapist to progress their career they have to do further training and get certification in either manual therapy, acupuncture, dry needling, diagnostic imaging, injections, or even prescribing medications. For an MSK physio to be seen as advanced, enhanced, or specialised they have to twist, contort, and turn themselves into some bastardised version of a doctor, registrar, or radiologist. I know this because I am one.”

    In Australia, the Australian Physiotherapy Association, representing 26,000 + therapists, is on the one hand pushing for training extended scope physiotherapists in disciplines such as rheumatology and pain management, whilst on the other hand it is endorsing courses in Dry Needling (focused upon the neurophysiology of pain and myofascial trigger points) as being suitable Professional Development Activities for its members.

    I agree that the promotion and advocacy roles you mention are important gaps to be filled, but I also see a danger that recommended training in pain management will be based upon the neurocentric dictum that “pain is an output of the brain.”

    The important existential dimensions of the experience of pain may not be included in such training and, as a result, physiotherapists will be nothing more than biomedical poor relations.

  7. Great read!
    Just two thoughts:
    1. If we get into gyms(as an example) are we not stepping on other professionals roles like Sports therapists? (A big role that they do see in uni is about health promotion…)
    2. Is it just msk PT or does medicine need a global shift to a different approach? (Rhetoric question as I do think this is the case). Have you seen Ian Harris’ talk ‘Surgery: the ultimate placebo?’? If not here is the link https://youtu.be/IzueFu1cq5U

  8. I love this blog- if physiotherapist health promotion roles existed in my area, I would be in one! I feel like I spend my time doing this anyway with the patients who present to my clinic, but if we could speak to people before the pathology develops, how much more impact could we have?
    Well said!

  9. Hi Adam

    Thanks for another thought-provoking post.

    I am in the final year of my physio studies, but have been fortunate enough to have positive influences who share your emphasis on a proactive approach to health.

    Cheers

  10. As a physiotherapist working in primary care I believe health promotion is one of the key directions that our profession needs to move towards. Especially with a decline in physical education in schools and rising obesity worldwide. I just gave a couple talks to diabetes and women’s health promotion groups about the role of lean muscle mass on not only movement but also glycemic control. It always amazes me how little the general public knows about the benefits and importance of exercise not only for participation in leisurely activity but prevention and management of chronic diseases.

    This is where we as physiotherapists can become champions of active healthy lifestyle changes and have a great impact on improving public health.

  11. Couldn’t agree more. I assessed an ESP a few weeks ago who had a lateral epicondylopathy that they were trying to self manage with self administered acupuncture. An ESP???! They wanted to see a colleague who properly acupuncture it! I was dying to puncture her bubble and tell her she was talking shit but but my lip and tried a gentle approach to nature of tendinopathy and the role of exs. The response was beautiful, “I’ve tried some exs from google but they didn’t help!”. This from an ESP! Thanks for adding the articles.

  12. I have been delivering Exercise Referral for 14 years am a Reps Level 4 instructor qualified to take Cardiac Phase IV, Pulmonary, Stroke and other long term neurological conditions, lower back pain, Cancer patients and PSI Falls in a rural community. I love my job…seeing people for 16 weeks twice a week achieving their life changing goals (being able to bend down and make a fire again, putting their socks on, getting out of a chair without using their arms, going upstairs without holding on, reducing their stick dependence, improve balance….list is endless) I recently turned down a bursary funded physio degree because I am unable to study and fund my childcare, and then live on top. I have been feeling a bit deflated about this as I would really like the ‘credit’ for the work I feel I do, but your article has made me think twice. As I would definitely miss the joy, banter, rapport and appreciation from my referrals, maybe next year…

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