Musings of a physiotherapist in isolation

** title is merely a reflection on my covid exposure, and is not for dramatic effect**

This blog post has, I kid you not, been in the works for 3 years. It is an opinion piece, and I suppose my main goal is to try shed some light on the current practice of physiotherapy. I wouldn’t say I’ve had a long career, but already I’ve gone through waves of trending practice and treatment styles. I think this is likely inevitable in any field, but what concerns me is the extremely divided and antagonistic camps of various physiotherapists. I am motivated to explore this because I find physiotherapy practice an incredibly difficult area to navigate as a student or a new graduate, and even more confusing as a patient seeking services. I think for this blog to make proper sense, it might be helpful to describe my own little journey in the physio world. 

I first wanted to become a physiotherapist because (as most of us will say) I wanted to help people. When I was in school, I used to say that I thought physiotherapy was the perfect blend of art and science. To my own understanding at that point, there was a genuine talent with hands on skills required to help people feel better, as well as the scientific rigour of evidence based practice, a knowledge of anatomy, physiology systems, biomechanics, etc. I loved every aspect of the profession, but I really enjoyed the fact I could help people relieve their pain with my hands. I would watch senior physiotherapists manipulate or adjust areas on their patients, and the patient’s pain would immediately resolve. This was nothing short of magic in my eyes, and I wanted to be the very best at it.. The physiotherapy profession aids this thought process by having manual therapy levels and certifications that signify how skilled you are. You can chip away at these for years, and when you’ve reached the highest certification you can, you learn how to manipulate (adjust) the cervical spine (I will happily discuss this in another blog- how our “highest achievement” in physio is what we routinely like to give chiropractors crap for).  All I wanted was to get every certification I could so that my ability to perform miraculous treatment was never limited. 

When you’re in school, it’s a common saying that you need time and practice “gaining your hands”, meaning sharpening your manual skills. I happily put time in at a super busy clinic so I could treat as many people as humanly possible. I then set out to Australia, where I had heard they had the best manual therapy training in the world. I wanted to be able to diagnose and physically treat every condition someone could ever come in with. The university I chose was hugely into evidenced based practice, so what I was introduced to was a lot of pain science and clinical decision framework, which is probably best known in practice as a biopsychosocial approach. This has just started to become more widespread in Canada in the last couple years or so. While I knew chronic pain was complex and multi factoral, I don’t think I had a good grasp of what evidence was currently saying about many conditions we treat in practice, and how we handle people’s pain. For the non-physiotherapists out there, we (like any allied medical professional) are supposed to be evidence based. This means that there are rigorous studies that back up our treatment approaches, and that when you test a certain treatment against a placebo or no treatment, it should hopefully outperform it. 

The issue is, we don’t have great evidence for a lot of what we do. Exercise probably has the strongest evidence backing (for other general positive health outcomes), but even that treatment option hasn’t been tested well. This becomes complicated when we look at the studies examining the impact our words have on patient’s diagnoses and treatment options. If I needle someone’s back, and adjust their spine, and I tell them they are out of alignment… that person could interpret my treatment as their back is vulnerable. I might have helped them feel better, but I’ve now potentially limited their function. Clinically, I see this often. Patients will have heard things such as “weak core, unstable SI joint, slipped disc” all of which are very alarming. Even more importantly, they aren’t accurate. The SI joint, as we know through numerous studies, is ridiculously stable. When we “adjust”, we aren’t specific, and we sure as hell aren’t putting anything back into place. Discs do not slip out of place or squish like a jelly donut. What happens is we run the risk of patients becoming nervous or interpreting feeling uncomfortable as a sign something is wrong and they move less. When they come to a healthcare provider, and they hear language that something is bio-mechanically wrong with them, they can become reliant to being “fixed” any time they feel uncomfortable, or they become reluctant to move. Our field of practice is filled with nocebic language that has been shown to have negative impact on patients outcomes. 

The knowledge of these outcomes, in combination with studies that haven’t shown manual therapy to have the effects that we generally sell and pitch to patients, has lead some physiotherapists to advocate against using manual therapy at all. This is where camps have become divided, because a lot of physiotherapists who are vocal on social media platforms are against using passive (including manual) therapies as a whole. Of course there will be professionals in any industry who want to practice differently than their peers, but there is such an extremely wide spectrum in physiotherapy it can be overwhelming. In addition, physiotherapy is privatized and therefore there are strong business aspects to this healthcare/clinical setting. This gets even trickier- as a patient, you want to make sure you are getting good and honest care. The definition of good and honest care varies so widely by practitioner that it becomes difficult to establish what is the best care for you as an individual, what makes you feel better, and then what actually makes you function better, etc.

As a new physiotherapist you are striving to make people feel better, and having courses and certifications under your belt can really aid you in feeling like you know what the heck you are doing. Now we have a large group of practitioners vocally saying that these manual therapy and assessment techniques don’t matter. After a few years and experience under my belt, I would agree with that statement. We aren’t as specific or fancy as we think, and we aren’t changing the body as a system like we think we are. You could likely have a very pleasant conversation with a patient and not apply passive treatment to them, and if you’ve made sense of their pain, they will leave feeling better. This is a hard thing to accept as a physiotherapist… when I first started to be suspicious that my manual skills aren’t likely that important, I felt like **spoiler for Harry Potter- although if you don’t know the details of Harry Potter at this point that’s on you** when you discover Harry Potter isn’t that particularly powerful or special of a wizard, he was just picked by Voldemort as his counterpart for a prophecy. It was sad to read! We want to feel special, we want to feel unique and like wizards to our patients. However, chasing that wizard status is sure to leave you feeling disillusioned after a couple years in consistent practice.

The average physio has a massive fork in the road when trying to figure out their career- the manual therapy based camp and non manual therapy based camp (and strictly evidence based vs loosely evidence based) are each helpful and each valid. The issue I have is the attacking of the respective camps. Physio and med twitter is perhaps the most helpful and treasured tool I have for continued learning in my career- yet I’ve never tweeted or posted. I follow countless physiotherapists I admire for different reasons, and I can’t express how disheartening it is to have them feuding. It’s also extremely intimidating, and open questioning or posting of ideas can often lead to hostile twitter show downs. Disagreement is not the issue- of course varying opinions are incredibly important and educational. It’s the attacking and implying that one’s treatment strategy is not in the best interest of the patient. It’s insinuating that their assessment or treatment technique could be negative to the patient. That’s very hard to hear or accept as a physio, because like I said previously, we go into the profession to help people. We promise to do no harm. We need to find some kind of common ground as a profession, for new grads but also seasoned physiotherapists. Patients/clients would also benefit from this- ask them what their “physio” consisted of and the responses can be all across the board. We advocate that physio is a profession and not a treatment, but our profession feels split in half. 

When I was in Australia I was shocked to hear a stat at Curtin University that the average career of an Australian physiotherapist was about 2-3 years. After being home in Canada for awhile and talking to fellow practitioners, I can see why. We are all over the map in what we offer to patients. Add in the complexity of us being privatized and a business, and things become even more muddled. As a physiotherapist, it is very easy for me to set myself up to make someone feel better and leave it there. We can do massage, manipulate, needle, heat, the options are endless. The current method of practice that is touted as best care is one on one, hands on therapy. We can work to make people feel really good in their 30 min appointment using passive treatment and they will likely feel better, and then need to keep coming back. From a therapist point of view, I think we become burnt out when the entirety of our day and our treatment blocks becomes like a servicing of the person. It doesn’t matter if you are super skilled, if you are massaging and mobilizing and needling person after person, you feel like a factory worker. Add that in to knowing your profession is at war with themselves on if any passive therapy needs to be done at all, and what a confusing time to be alive. From a patient point of view- manual therapy feels great. You want to feel like you’re being “fixed”. From a therapist point of view, we know we haven’t “fixed” you.

I think there is skill in how we use our hands, whether that’s assessment or treatment. We can intuitively say this because we’ve all had good massages and bad massages (and that will vary from person to person on what their opinion of good and bad is!) I think we can learn these skills from other practitioners who have done amazing things in our field. I also think it’s not necessary to use these skills… but there in lies the debate, should we bother learning the skills at all? I don’t know the answer to this. I only know it would’ve been very difficult for me being a new grad and then deciding to not learn any hands on techniques and feel confident in my practice. I think it’s easier to gain the confidence and experience in a role, and then decide what tools you can clear off the workbench, rather than do without them to start your career.  That could just be me… but private clinics also benefit from manually skilled practitioners. Hell, myodetox has built a massive following from marketing skilled hands on treatment. These treatments are usually applied to address “movement and postural faults”, something the evidence based camp of physiotherapy would tell you we have no evidence to suggest even exist. Same with dry needling. We have 0 evidence that this is helpful… there is also no evidence of trigger points. Can you see how muddled this is? Patients seek out treatment that are advertised by manual practitioners and needlers, clinics seek out these practitioners to provide theses services and meet a need, and all of a sudden you have a routine business of “tune ups”. The business practice has been separate from the evidence for awhile. .

I don’t have answers, I just felt motivated to write something out into the void. I think I started this post as something anyone could read, but if I’m being honest it’s primarily a shout out to the practitioners who have been in this field and are burnt out or want a career change. Or for new grads that have no idea what direction to go. We are expected to spend thousands of dollars on certifications that are then insulted by a chunk of our profession. The more educated we become, the more divisive our colleagues seem. We become more and more skilled, and yet our days become increasingly simple in practice when all we are doing is poking and prodding people and seeking the result of decrease in pain, which, pardon my language- is a fickle b*tch. Pain is complex! I want to be more helpful to a person than a glass of alcohol and a heat pack, and I think my colleagues do to. I also want to be ethical and honest, and offer pain relief but inform that there’s hundreds of options for that… pain relief does not equal fixing something. I know in another way, it’s easier to just massage/mobilize someone while they are on the table and zone out. The hardest thing, is to get the person moving. When we hurt, we protect. We want to not move. So do our patients… and they are the most likely to try move and relearn motion when they are with us, and so that time in clinic is critical. Yet we also need to provide trust, and movement feels easier if there is less pain… It is such a fine line, and at the end of the day every patient is different. Every practitioner is different. 

For myself, if anyone cares, I have settled on a practice philosophy that pain relief (however I provide it), is valuable and still so important, if it allows a patient to move and function better. I am so grateful for all my manual therapy training under my belt. If I educate and explain why what I’m doing may improve pain, and then explain how they can provide similar relief to themselves at home through movement, I feel like I’ve done my job. I’ve also made it clear that the ticket to their recovery is not in my hands. Pain relief, including manual therapy, I have found to be helpful for the vast majority of my patients, because it’s how I feel comfortable assessing and treating. I needle patients, IF they find it helpful for movement and pain relief. I’m okay that there’s no evidence for it and I regularly communicate that to patients. If I’m being honest though, when I myself am hurting, or my husband, I reach for a needle to ease muscle pain. Or I mobilize the area. I treat patients how I treat myself and my loved ones, and I explain the narrative to them. If your hip flexor is giving you pain and I do something to make your movement improve, here’s what your body told me. Here’s what movement would be helpful for you to maintain that new range of motion. 

To patients who might be reading this, I’m sincerely sorry our field is so confusing. The best advice I could give is to find a therapist who is diligently working to not to have to see you consistently. We should try and work ourselves out of a job and to “fix you for good”.That HAS to include some kind of measurable outcome and goal agreed upon by you. In my humble opinion, if all we do is hands on skills, we haven’t really “helped” you as a person. We might help you temporarily feel better, but what do you believe I did to you? Can you recreate it? Do you feel confident moving and lifting? Pain relief is important and valuable, but it’s phase 1 of getting you better. I think function is an important outcome measure for actually helping someone. 

I love this profession. I feel so lucky I have, in my opinion, the best job in the world. I had the crisis of my life when I thought I wasn’t helping my patients because I was needling them and using adjustments and manual therapy to make them feel better. I also got burnt out when that was the only thing I was doing with them. I don’t know how I would’ve navigated that if I was brand new to the field. I just want to help people move and function better. I think we need to follow evidence based procedures, and test things, but also be okay if a treatment just simply makes that person feel better for a little while. I think mostly, we need to stop being so divided in our professional development. We all got into this field to help people, and there’s many different ways to do that. Different strokes for different folks!