Why don’t physios exercise? by Nick Emery

So the NHS has reached 70 recently, but what does the future hold for it? The report ‘How Good is the NHS? highlighted that overall the NHS did OK, and considering it has fewer staff and spends less on health care per capita than the majority of similar counties we should be hugely proud of our NHS and give ourselves a big pat on the back.

But the NHS is far from perfect, in fact, this report also highlights that the NHS fails or is poor at treating a long list of conditions such as;

  • Breast cancer
  • Colorectal cancer
  • Lung cancer
  • Pancreatic cancer
  • Lung disease
  • Stroke
  • Heart attacks
  • Diabetes
  • Dementia

These non-communicable diseases place a huge burden on the NHS financially and through hospital admissions, but you may be thinking what have these got to do with physiotherapy and me? These are all medical conditions and I’m a neuro, orthopaedic, respiratory, community, paediatric, or some other physio; These conditions are not my problem or responsibility. Well, they are.

Physiotherapy should be at the forefront of prescribing the best available healthcare and this includes exercise. We are one of the few healthcare professions (and I use that term ‘profession’ lightly in this respect) that has significant face time with a great many people that are in need of guidance, signposting, and education of the importance of exercise. However, a recent paper by Lowe et al 2017 found not only do UK physiotherapists have a mediocre knowledge of the very basics of exercise, but the vast majority do not do the bare minimum amounts of what is considered necessary to maintain a healthy life.

Physical inactivity has a significant impact on morbidity and mortality (Lee, et al 2012). Physically inactive people spend 38% more days in hospital and use healthcare resources significantly more than healthy active people (Sari, 2009). Many of these inactive people turn up in our physio clinics or outpatient departments seeking our help, often due to the consequences of their inactivity which start to manifest and affect their ability to function. But how many physiotherapists discuss, encourage or facilitate these patients to engage in basic lifelong exercise?
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Well in the recent Lowe paper they found that a favourable 77% of UK physios discussed exercise with their patients, and 66% routinely delivered brief exercise interventions in their treatments. Unfortunately, the paper does not detail what these brief interventions are, but I suspect it is the usual 3 set of 10 reps bollocks with a flimsy yellow theraband, which seems to be the default go-to exercise prescription for most physios.

However, far more disappointing is that only 16% of physios correctly answered the questions about the content of the physical activity guidelines. This is just inexcusable. These guidelines are not hidden in some secret bunker, they are freely and easily available through various channels (DoH, 2011, WHO, 2017, ASCM, 2011) and should be instantly quotable by all physiotherapists. It’s such basic knowledge.

So where does the fault lie that so many UK physios don’t know this stuff? I guess we can blame the universities? And, yes some undergraduate courses don’t teach or have a module covering exercise in any great detail. And if they do, how much do the students engage with it and to what extent is the importance of exercise promoted? Very little I suspect.

Really the fault lies, with physiotherapists themselves not bothering to learn something that will, if used correctly, change the lives of all the people they see, as well as eventually save the NHS and wider society billions of pounds and develop a more productive, able population.

For example, in 2002 obesity alone cost the NHS £2 billion (Butland et al 2007) and by 2006 this was over £5 billion (Scarborough et al 2007). Now I’m not suggesting exercise alone can address the obesity issue, but it is known that those who exercise more often tend to be more diet and health conscious. Unless we get this under control the NHS is heading for a tsunami of health-related issues on this one issue alone. Could the NHS survive when projected costs of obesity alone are expected to be in the order of £10 billion by 2020? Probably not?

We, therefore, need an NHS that is proactive in addressing and combating these issues before they occur, not wait until a population of people waddle into our hospitals with arthritic knees and low back pain, or flood our A+E departments with strokes and heart attacks. As physiotherapists, we need to start looking at how we can help prevent these conditions before they occur, and not only treat them when they do, and the best we can do this is to promote exercise more… a lot more!IMG_4869
A lot of physiotherapists are quite happy to spend hundreds even thousands of pounds on some poorly evidenced course so they can become ‘experts’ in manipulating joints, sticking pins into people, or releasing tight facia, but would not dream of going on a course that teaches them how to prescribe the basics of an exercise program that can be safely adhered to?

To make matters even worse is this latest campaign from the CSP, our so-called professional body called “Love Activity, Hate Exercise?”. Now, this campaign may seem on face value to be well-intentioned but it sends out completely the wrong message. Increasing activity is a good start but it is NOT sufficient to reverse the effects of sedentary behaviour and poor lifestyle choices.

A gentle stroll or some fannying around in the garden now and then will have little or no effect on promoting meaningful physiological adaptations needed to maintain or improve health. The CSPs own website doesn’t even state the correct WHO guidelines for physical activity stating that; ‘only 50 per cent of UK adults do the recommended minimum of 150 minutes of moderate to vigorous exercise each week’.

Well, what about the 2 sessions of high intensity and/or whole body strengthening exercises per week that are also recommended by the WHO? Why have these been omitted? Is this ignorance or are we too frightened of scaring or upsetting people to tell them they need to get up off their lazy arses and do some hard intense exercise a few times a week?

Not only do a lot of physiotherapists not know the recommended amounts of exercise, even more, don’t do any regular exercise themselves. In the same Lowe et al paper, only 38% of the physiotherapists who responded reached the minimum recommended amounts of exercise, this is even less than the general population, and we as a profession are supposed to be leading by example.
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Again it seems that many physios are quite happy to poke, massage, pin, tape etc. but to get them to do some exercise themselves and show their patients a healthy, fit, strong person is just too much to ask. If the results from the Lowe survey are applied across all of the physiotherapists registered in the UK, then some 32,000 physios are doing little to no exercise, and they then have the audacity to try and tell their patients to do more. Is this something as a profession we should be proud of? Hell no!

I, for one, hate seeing overweight, unfit physiotherapists struggling to bend down to examine a patient, to climb some stairs, let alone trying to demonstrate an exercise to their patients; simply put there is no fucking excuse for this.

I do appreciate that regular exercise is not easy for everyone to do, or stick to, but it needs to be sold to patients and undertaken by us all as healthcare professionals. It needs to become part of our daily lives just as brushing our teeth, washing our faces, or getting to work on time is; it needs to become part of our daily routine and a positive habit.

Yes, regular intense exercise is hard to do, but its a hell of a lot easier than having to live with the after-effects of a stroke, or a heart attack, or type 2 diabetes and becoming a burden to your family and wider society.

So to all the physio’s out there, put down that cream cake or that slice of pizza, don’t have that 3rd glass of wine or that 4th can of larger, get up off your lazy arse and go do some intense, challenging exercise, and do it often. Be the example and motivation for your patients, lead by fucking example.

As the great philosopher, Bertrand Russell once said “people would rather die than think, and most people do’ just replace ‘think’ with ‘exercise’.
Thanks for reading

Bio: Nick came to physio late in life after 18 years as a London Fire Fighter and qualified in 2005 from Keele Uni. He works at the Robert Jones & Agnes Hunt Orthopaedic Hospital in deepest darkest Shropshire. and also has a private clinic at a climbing centre called The Boardroom (www.theboardroomclimbing.com) where he treats climbers with a wide variety of MSK problems.



  1. Nick’s reference to ASCM 2011 reveals exercise isn’t getting a lot of blood to his brain.
    I presume he means the ACSM (American College of Sports Medicine). That link doesn’t state recommended activity levels.
    And he confirmed his cerebral hypoxia with Bertram Russel, presuming he meant Bertrand Russell.
    As for the activity recommendations, yes most non manual labouring people are excessively sedentary these days.
    However, the chronic diseases that provide a physio’s income are driven by what Nick says in his last paragraph…… “put down that cream cake or that slice of pizza, don’t have that 3rd glass of wine or that 4th can of larger…..”.
    One can avoid arthritis, muscle strain, ligaments and capsule sprains, atherosclerosis, and insulin resistance by just maintaining healthy bodyweight and managing stress better. Of course, some activity helps, but it is not the primary driver of Western chronic disease.
    All this begs the question, should health care be split up into exercise, nutrition, etc. Health care should be discussing the contribution of all these things with appropriate weighting to each. As we know, one cannot out exercise a bad diet.

  2. This is a stunningly simplistic view of the complicated human beings we see every day in physical therapy. The writer seems to think that the problem is that people(and PT’s) are a lazy lot. And what then? The slobs are worthless and they’re weak(to nab a line from “Animal House”), and they’re bound to be miserable and then die. Have you no knowledge or understanding of the effects of ACEs? Do you really think that intense exercise makes better physical therapists? It seems to me that the establishment of a healthy, active lifestyle starts at home and school. If that’s not happening perhaps you should ask why. I’ve nothing against intense exercise, I daresay I’ve done more of it than most, but I certainly don’t see it as a panacea of health, many of the kookiest people I know are devotees of intense exercise. If you’re determined to beat the this singular drum to the exclusion of the many other approaches to dealing with pain and disability you’re writing off a whole lot of patients.

    • Hi Kevrei, I dont think Nick says or thinks exercise makes better physios technically or mentally just physically. Physios need to be able to do task that the job requires, many cant!

  3. Great post Nick…this has prompted me to get on and deliver ‘a Good Fitness guide’ for our website…this we at least make delivering the info to patients easier for our users. I’ll also be more compliant to my boot camp workouts !!! Best regards, Gary.

  4. Another provocative post, thank you. Within the Canadian context, the pre-licensure training program is a masters degree of 2 years in length. Despite the fact that many applicants enter the program with an undergraduate degree in kinesiology, exercise science, etc., many don’t (and that’s a good thing!). Two years is simply inadequate to provide the graduate with the breadth and depth necessary to meet the demands out there. IMO, the move to wrap the program in graduate degree was a huge mistake, and the exercise component is just one example of deficiency attributable to this degree creep. It also inflates the price of services without evidenced concomitant increases in value. Then, following graduation, the continuing education opportunities (again, within the Canadian system) amount to a hodge-podge of information that could better address the exercise component. In fact, the entire continuing education approach needs a good shake up, but Adam has wrestled much of this previously.
    This article has many aspects to tease apart further still, but Nick has made some excellent points that are hard to rebut. The common theme seems to be one of lack of identity, yet leaders remain invested in the status quo and except for a very, very few, the profession refuses to engage in critical discourse, or accept that it is vital for the future of PT.

  5. Hi Nick and Adam, this latest post; creates conflicting emotions in me. I read this article as I fear that I am not the role model I could be for people who come to our practice. I hungered for the evidence that I was not alone and that it was not my fault; my apathy. I found it hard to read the entire article as I found the points to be like stabs of a sword honed with research from reputable organisations at my fragile ego. I went seeking some reassurance that many physio’s like me are not the role models that we could be. I have the evidence and the status in community but for many I simply speak dogma and doctrine. I find I don’t have to use much effort; just do this, like that. I believe people have access to information and knowledge about exercise and its benefits, but many don’t do it. I believe my approach to motivation,like this article is to evoke emotions; anger, fear, disgust and this can be one way to get a person to do something; to react or to obey; like write a comment to an article :). How I perceive myself as, influences what I can do. Self-righteous, indignant will create self-righteous, indignant actions. Knowing when to push, not push is a key consideration for working with people including myself as a physiotherapist. Each person is at a different place within their perception and beliefs. I believe people now are less influenced by doctrine and dogma and are seeking leaders who can help them to create more happiness, health and success in their life. I believe we have a responsibility to be wiser and better leaders for people to help them achieve this. The article did not influence me greatly and that is disappointing, as I believe it deals with an important point; how to make better leaders within our physiotherapy profession. Individuals who inspire; contributing to better outcomes for the people they are with and themselves. I would appreciate your thoughts and action on this and how as a profession we can develop better leaders. There are courses that are available that I believe contribute to this goal, that focus on the person and the qualities to develop to be a better person and practitioner not having the latest fad or best thing; As Jim Rohn said: work hard on your job and you will make a living, work hard on yourself and you will make a fortune.

    • Hi Robert, thanks for your thoughtful and insightful comments. I think (and I speak for myself here not Nick) that this article was always going to spilt and divide opinion, some good, some bad, some agree, some disagree. However, the main point of the article is to get the conversation started around physios and exercises rather than just ignore it and from there I think things could happen for the positive. Cheers Adam

      • Yes the article was exactly that to get people talking thinking about their own practice knowledge and physical activity. Interestingly I’ve just been told that it was not appropriate for me to do this blog as it could be considered to bring where I work in to question with regards to the ability of the physio staff. Are egos really that fragile?

    • If I may, Robert, your comment to my eyes is an inspiration for the simplest of reasons, its vulnerability and candor. While I agree with the author on points, and I agree with Adam on the need to think critically, I also firmly believe that these kinds of conversations are necessary and healthy. I would like to thank you for expressing yourself the way you have. You have taken ownership of your opinion and framed it within a larger social context, and by doing so here, you have opened a window for those in the profession who are ready to introspect. We (members of society) often stigmatize those who do not fit our view of ‘normal’, and you have provided some light on this. Anyway, good on ya! Thanks Robert!

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