One of my major frustrations at the moment as a Physiotherapist is that a lot of what’s being done in Physiotherapy is damaging our brand and in my view, unethical.
“Some will use the ‘what’s the harm’ argument and suggest that any benefit – even that of a placebo – is worth the effort. I disagree. The medical profession decided long ago that selling placebos to patients was unethical, no matter how convenient or profitable it might be.” Dr Christopher Labos.
Norwegian Physiotherapist Sigurd Mikkelsen recently composed this, which I have previously shared here:
“the ultimate paradox of pain and therapy: the problem is not that nothing works. The problem is that ANYTHING can work…usually just long enough for someone to empty their wallet!”
Science writer Paul Ingraham elaborated on that and points out that “‘science’ seems to be telling us that “nothing works” in spite of almost ANYTHING working in clinical practice, at least at first and usually only TEMPORARILY because that’s the nature of pain. No matter what’s causing it, pain can be tuned by any comforting and reassuring experience, and good therapists can cleverly fiddle with ten thousand variables to create that experience for their clients, creating potent illusions of efficacy… but, in most cases, the benefits don’t last long, or they last just long enough for natural recovery to assert itself, creating a strong impression of a true cure.
And there’s the rub; there are far too many Physiotherapists who make their living by “amusing the patient while nature cures the disease,” with an endless stream of elaborate treatment rationales and ‘therapies’, all based on the idea that they are “fixing” something, when in fact 95% of it is just theatrical, irrelevant variations on the same basic principle. They almost all work a little bit for a while for the same reason, but everyone’s selling a different reason. Therapists really are helping people… but not the way most of them think.”
In my opinion, I think it’s frequently driven by simple ignorance rather than a misguided ethical compass.
*Some* models of Chiropractic care have clients paying for ‘adjustments’ months in advance; I briefly worked for a financially very successful Chiropractor who did just that, and I bought into it as a patient too. Some Physiotherapy practices are now starting to offer a similar thing – having clients commit at the outset to months of treatment. The Chiropractor told me that the adjustments that I *needed* would correct my various spinal curvatures (I didn’t have any symptoms at the time). Ultimately it made no different at all; I have Scheurmann’s disease and a 13mm structural leg length asymmetry so my curves were never going to change, contrary to what I was being told. Had I not received a 50% staff discount, that series of 2-minute adjustments would have cost me $1200.
Every new patient received three weekly adjustments, then twice weekly, once weekly, and eventually periodic adjustments indefinitely. At one point I asked if there was any reason for starting with three visits each week instead of two; the answer was “no”. A 30% increase in revenue I suspect was the likely reason. My old employer has been seeing a Chiropractor on a regular basis for 30 years; he likens it to brushing his teeth – “we brush our teeth to prevent tooth decay; we need adjustments to prevent [insert disease state]. That’s brainwashing.
I hope Physiotherapist don’t follow suit but there are hints of it starting to head in a similar direction.
Having someone with a non-medical presentation commit to months of treatment in advance are frequently based on the postural-structural-biomechanical and pathoanatomical models of care which the clinical evidence clearly shows us are out-dated and invalid. A great deal of what consumers of Physiotherapy are told from a biomedical perspective (and rationales given to them for needing treatment) are incorrect and unethical.
The scientific data which forms the basis of ‘evidence based practice’ tells us this. For example, the best intervention for an acute episode of low back pain is a program of self-managed non-specific general exercise – literally *any* form of physical activity you’re physically capable of doing, enjoy, and have the means to do regularly with relative ease of access, plus some education about the condition or symptoms you have. Imaging is *not* indicated; in fact, the literature suggests a WORSE outcome for patients who are lead down that path and have their symptoms pathologised e.g. “I’m very sorry Mrs Smith, you have discogenic low back pain”. That’s about as useful as telling Mrs Smith “I’m sorry, this is a painful case of grey hair-opathy and wrinkly skin-itis”. Skin wrinkles; hair goes grey; lumbar discs change in size and shape – it’s called aging.
Manual therapy can temporarily alleviate symptoms, but with the wrong communication and a lack of knowing the specific and non-specific effects of that treatment, it can also rob the client of the one thing most important to their recovery – self-efficacy. Pretty much EVERYTHING improves within 3 months – many aches and pains in considerably less time than that; even a broken bone is typically ‘useable’ within 6 weeks, and that’s nothing to do with ‘Physiotherapy’.
The human body is remarkably plastic and designed to heal. If you’re broken, our most important role is not to heal you (that’s what a witch doctor does); it’s to steer you in the right direct, provide you with the necessary tools (knowledge and skills) if you don’t already have them, and protect you from yourself if you’re doing too little or too much which might negatively interfere with the natural history of repair and recovery.
Imagine what might happen to a GP if they deliberately misdiagnosed a common cold and started you on a 3-month course of medication which you didn’t need and which had known side-effects; they’d lose their licence to practice.
I feel really uncomfortable hearing stories of people being sold treatments and promises akin to providing antibiotics for a viral infection.
Too often people have what’s called maladaptive beliefs and behaviours which have been created by a Physiotherapist. Beliefs about symptoms which are incorrect; believes about treatment that think they need or would benefit from which are incorrect or the treatments themselves are ineffective; expectations of me as a Physiotherapy or the profession which are unhelpful to both of us.
To quote Professor Peter O’Sullivan:
“…we have to change what we value in a consultation. The advice we give and the strategies we empower people with are maybe way more important than the (manual) techniques we apply.”
“…but I’m in there with my hands. Because TOUCH is a powerful communication tool that can guide people to safely move. The (manual) skills are very useful, but the thinking is different.”
Time will tell I guess.