Why you don’t need daily physiotherapy

TheKettleBellPhysioUncategorized0 Comments

This follows on from earlier posts about “low value healthcare” in Physiotherapy previously discussed here and here.

It would be absurd to suggest that the “best” way to lose weight is to employ a personal chef and have them prepare all your meals. Why – because you can prepare your own damn food!! You just need to know what to eat and how much. I once heard of an overweight family who had five different types of fast-food each week and genuinely thought that was a balanced diet because they had variety. An appropriate long-term solution for that family would be education and guidance, not a personal chef.

There are many reasons why someone might be overweight; it may not just be about the ‘what’ and ‘how much’. Psychological and social factors can have a significant impact on eating behaviours. No matter how good a personal chef may be at preparing great food, he or she is probably not appropriately skilled to address emotional, psychological and social factors negatively affecting eating behaviour.

Some people can afford a personal chef. I suspect though that the likelihood of those people being slimmer, healthier, or on average having lower bodyweight ‘because’ they have a personal chef, is absolutely zero.

Some people are professional sportsmen and women who have access to a team Physiotherapist. That Physio is paid to ‘attend’ to the players (whether they need it or not). If that individual becomes injured, they would likely see the Physiotherapist every day and receive more time and attention. But does that mean that if ‘Jo-Public’ is injured they would be any better off seeing a Physiotherapist daily because the professional footballer does?

Absolutely not. It’s an absurd comparison, but one that is made to justify regular treatments.

A professional footballer has the luxury of having a team paying for a full-time Physiotherapist. It is inevitable that the players will receive treatments, a) which have no specific efficacy, and b) whether they need it or not. There are lots of practices in a professional sport setting which exist simply because the players have time on their hands, the team will throw everything but the kitchen sink at them if they believe it will make a difference on game-day, regardless of clinical efficacy e.g. pre-game strapping and taping, post-game ice baths.

If I was a personal chef I could prey on the insecurities of the overweight and sell my services as a solution, but that wouldn’t really be very ethical would it?

This comparison makes a *lot* of assumptions. There is of course a spectrum of ‘injuries’ from an innocuous strain or contusion, to supraphysiological overload, to trauma such as an ACL rupture. Each requires a very different management, if any at all. A contusion (bruise) doesn’t require ‘physiotherapy’ as it’s not a medical condition – your mum can fix that for you. A strain may require a change in ‘loading’ and management of an active rest period; how much of that the Physiotherapist is involved in may depend on the involvement of a trainer/coach responsible for the player’s training schedule. A player side-lined for months following a knee reconstruction would likely have the Physio holding their hand from start to finish, but would ‘Jo Public’ be any better off seeing someone daily? The answer is definitely not.

For a professional sports player, the potential ramifications of a knee reconstruction are entirely different to ‘Jo-Public’. Preparing food for a critic who may be awarding Michelin stars to a restaurant is an entirely different ‘need’ than ‘Jo-public’ cooking dinner for the kids every night. Jo-public needs daily Physiotherapy as much as they need to be able to prepare a Michelin star-quality meal.


Let’s assume that the Physiotherapy intervention in question is the ‘medical care’ which Erik Meira discusses here, not the low-value consumer service which the Australian Physiotherapy Association is trying to stamp out! If you’re wondering, low value physiotherapy is everything which only serves to make someone ‘feel better’ i.e. it has no efficacy doesn’t do anything specific, like ultrasound and K-tape.

Assuming we have a diagnosis, the primary role of the Physiotherapist is to protect an injury from further harm and create an environment for an effective and efficient normal process of repair.

In terms of recovering from injury and tissue repair, the role of all manual techniques is very limited as they cannot induce the required adaptive tissue change. Tissues have a loading-to-adaptation threshold which are often many times the force that can be generated by manual techniques. ‘Movement’ is also a brain-driven top-down process. Manual, ‘bottom-up’ processes are insufficient to change movement patterns for effective rehabilitation in this context.

The human body has an innate self-healing capacity i.e. it will heal pretty much regardless as what we do. That can however be made better or worse by what we do. If we under-load or over-load a tissue, recovery may not occur as quickly or as effectively as possible. The role of the Physiotherapist in that case is to maintain an appropriate loading-to-adaptation threshold for tissue repair. We help guide the individual and create an environment in which the individuals ‘recovery behaviour’ supports the desired adaptation. Where helpful, we have different means of modifying symptoms to assist that active process, and that’s pretty much it, if we exclude the low-value treatments.
Dr Eyal Lederman (PhD) has identified three processes through which a person recovers from injury here: 1) repair, 2) adaptation and 3) alleviation of symptoms.

Recovering from an injury could be one of simple tissue repair or, it could be more complex with dysfunctional tissue and motor control adaptations, such as following immobilisation in a cast. The role of the Physiotherapist in each situation varies. However, given that we know manual interventions are insufficient for tissue adaptation, what then is the role of the Physiotherapist? This image shows seven treatment tables in a team locker room; hopefully no team has that many elite athletes broken and disabled that they need to be on a table for anything other than a rub (which is a low-value treatment)!!

A change in symptoms may play an important role in recovery. For the purpose of this post, I’m referring to symptomatic recovery from pain, stiffness and paraesthesia specifically associated with an injury, not those associated with chronic conditions or states of dis-ease. Passive interventions have their place in rehabilitation, however, movement and manual techniques that are passive or dissimilar to the individual’s recuperation objectives are far less effective in supporting functional recovery.

In other cases, such as back pain, we know that symptoms resolve without tissue changes. If the intervention is simply ‘alleviation of symptoms’, then we’re back in the realm of low-value consumer services again. The clinical evidence and practice guidelines, such as the Traeger et al paper just published in the Australian Journal of Physiotherapy, clearly demonstrate the very limited role of Physiotherapy (if at all) in the management of acute back pain as it is not a ‘medical’ condition which requires a medical intervention. Interventions which have only non-specific effects (such as massage) which are used primarily for the alleviation of symptoms are considered ‘low-value healthcare’. Traeger (representing the APA), Meira and many others argue these should not be a part of Physiotherapy. If we are to be taken seriously as medical professionals instead of over-qualified Massage Therapists, we need to act accordingly.

There is a big different between providing clients/patients what they need verses, what they *want* Physiotherapy as a medical practice is not to placate ‘soothe-seeking’ behaviour.

Following an initial inflammatory period, regeneration and remodelling of tissue is largely influenced by the individual’s activities – what *they* do, rather than what we may do *to them* – that’s no more than a novel (and hopefully pleasant) sensation.

Resolution of symptoms is partly due to a reduction of inflammation and a decrease in nociception from damaged tissue. The nervous system becomes less sensitive and peripheral sites of damage and repair become less painful.

Faced with a significant injury in which we experience pain and loss of function, our behaviour changes to support the underlying physiological processes associated with recovery e.g. reducing weight-bearing on a sprained ankle. What humans “do naturally” is usually helpful and profoundly influences the adaptation process. Sometimes recovery behaviour can be maladaptive and the Physiotherapist has a very clear and valuable role in addressing that!

Many issues can most effectively be addressed with task-specific practices and task rehabilitation, such as sitting, standing and walking.

Acute pain has a biological role to prevent further damage and it typically decreases in line with repair; “active rest” is usually sufficient. Most people do not ‘need’ a Physiotherapist to hold their hand if they have a plan and understand it. The ‘SELF study’ from 2016 by Dr Chris Littlewood here is a perfect illustration of that!

So far, all I have addressed is the tissue and biological components of repair and rehabilitation. The recovery processes are heavily influenced by the individual’s physical-psychosocial environment. These factors support the exposure to beneficial movement challenges as well as having important psychological influences. These can have a positive effect on well-being and directly contribute to alleviation of symptoms. The role of the Physiotherapist is to understand those factors relative to the individual and ensure that they support rather than hinder their recovery.

Our role is not to “fix” people. People are perfectly capable of fixing themselves without us stealing their self-efficacy and creating a misguided and inappropriate sense of fear and dependency. Our role is that of a guide within a therapeutic relationship. We should be *giving* them a sense of self-efficacy, creating a sense of resilience and autonomy around a plan of care where the individual, not the practitioner, retains the locus of control.

Given that we each have an innate capacity for self-healing and recovery, Lederman asks the question, what is the therapist’s role in this process?
The traditional ‘operator’ role within a therapist-patient relationship needs to change.

Yesterday I shared this quote from Dr Adriann Louw: “If a patient has pain, teach them about pain, not anatomy.”

In an outdated structural approach, the client/patient is highly dependent upon the therapist with ‘things’ that cannot be self-administered, where a treatment table is often the centre-piece and the patient a passive recipient of care.

Most of the clinical management by the therapist can be replicated by the patient within their environment. A Physiotherapist has the role of health educator as well as supporting and facilitating the individual in their recovery process.

The suggestion that someone may be better off seeing a Physio daily because that’s what a professional footballer gets, is simply not correct. It is however a very good means of selling a solution in a consumer services environment where over medicalisation and over treatment serve to make a profit.

That is the low-value healthcare Traeger et al have discussed; it is not the Medical Professional Meira describes. That is a clever sales tactic of a practice in the business of selling Consumer Services for profit.

In the middle of writing this, I saw someone who sustained a partial thickness tear of their supraspinatus almost six months ago. The client had immediately started seeing a therapist with whom they had previously developed a high degree of trust and alliance with. In complete contrast to the SELF study, the therapist provided twice-weekly passive treatments (including ultrasound) for many weeks. Those treatments eventually dropped to once-weekly, then fortnightly. No outcome measures were used. There were no active strategies in place for managing pain. The client didn’t know anything about normal tissue healing times and had no active means of increasing tissue tolerance (home-based, self-managed exercises). They didn’t know what was helpful of not. Still symptomatic with no significant reduction in pain over 5+ months, they had not regained normal function and had completely withdrawn from usual physical activities. When I asked if they had gotten any better because of all this treatment, the answer was “that it must be better because I had been seeing the therapist less frequently”. WTF!

The lay person typically understands food and cooking enough to make an informed decision that they probably don’t need the services of a chef, or if they do, that choice is likely based on a sense of ‘want’ rather than ‘need’. Seeing a Physiotherapist and paying for Physiotherapy services is rarely based on ‘wanting’ to see a clinician, and that’s where we have leverage. The extreme knowledge imbalance between provider and patient creates limitations on the patient from the perspective of their understanding of needs, evaluation of quality, and assessment of price. People who are broken or in pain are susceptible and they are the easiest to sell to.

There is good reason why the Traeger et al paper just published in the APA’s Journal of Physiotherapy is entitled ‘Wise choices’.

Conclusion:
“Eliminating low-value services from physiotherapy care altogether will be difficult. Some clinicians and patients will find it hard to break old habits and new low-value habits will likely emerge. Others will find it hard to accept that some treatments and tests are simply not beneficial. On their own, ‘do not do’ lists are unlikely to change practice. Instead, clinicians need practical tools to help them discuss sensitive issues, such as over-diagnosis and unnecessary tests and treatments, with their patients. An increased understanding of these concepts among clinicians, policymakers, and healthcare consumers will be a good start. If we are to ultimately improve the value of physiotherapy care, the logical next step is to translate an improved understanding of low-value healthcare into wiser choices in practice.”

Inspired by and based on Lederman A Process approach in manual and physical therapies
and Ethics of healthcare advertising
Opinions my own.

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