Physio’s don’t do exercise

TheKettleBellPhysioBlog, Business, Evidence, Exercise, Health, Physiotherapy, The Kettlebell Physio0 Comments

That was the implicit message I received last week while talking to half a dozen GPs.

I was meeting the Drs to promote myself and PRIDE Physiotherapy as our practice is within walking distance from their medical centre, and to let them know that we’ll be bulk-billing all GP referrals for Physiotherapy until December.

I’m going to avoid this turning into another post about the interdisciplinary overlap of knowledge and skills, but I’ll admit that having invested so much time and energy over the past five years discussing the frustrations and challenges of professional overlap, I still left feeling quite shocked. I’ve clearly been stuck in my own little bubble. I shouldn’t have been so surprised; my wife’s a GP and co-Director of PRIDE, albeit a silent one, and even she has seemed confused by my focus on exercise.

In Australia, Medicare will provide funding for 5-10 Allied Health visits annually for patients with a chronic medical condition, if it is part of a GP/PCP-referred Chronic Disease Management (CDM) plan. For us, that represents a little over $50 per visit. An Extended Primary Care (EPC) referral recovers a wide range of professions.

An Accredited Exercise Physiologist (AEP) is a recognised Allied Health professional to whom a GP may choose to refer their patient as part of that CDM plan. Here is the ESSA Careers Guide and pathway to becoming an AEP.

I have a 3-year equivalent Undergraduate Degree in Exercise Science. It was a *pre-requisite* to my post-graduate Doctor of Physiotherapy Masters. If I had been heading in the direction of becoming an AEP instead of a Physiotherapist, to become registered with ESSA I was required to complete an additional 1000 hours of supervised clinical work experience. I didn’t.

I’ve trained in gyms my entire adult life – 26 years and counting – and was regularly involved in various sports in the 8 years preceding that. I’m a qualified Personal Trainer and used to teach a Certificate IV in Fitness to new Personal Trainers. I’ve never had any particular interest in Olympic lifting, so I haven’t gone down the Certified Strength & Conditioning Specialist (or equivalent) route. Instead, after graduation I headed toward the FMS/SFMA and subsequently the Russian Kettlebell Certification, which coincided with me developing a Myotherapy curriculum in 2013/14.

Before moving on from Myotherapy, here in Australia, Myotherapy is the only profession which *requires* students to learn the skills of dry needling as part of the curriculum. It’s a minimum of 60 hours which includes written and practical assessments and a component of clinical practicum. Acupuncture is different and hopefully you’ll understand why I am leaving that topic here.

In the land Down Under, Remedial Massage Therapists may complete professional development courses in Dry Needling and use it within their scope of practice if suitably trained. For Physiotherapists, the minimum is as little as a weekend course; 14 hours or thereabouts. None as far as I am aware come anywhere close to the 60+ hours within Myotherapy and its associated assessment of competency. Within the Section on Women’s Health at CSM this year, there was an Oxford-style debate on dry needling following the motion: ‘This house believes PTs should implement dry needling into practice.’ You can watch it here, and listen to Karen Litzy discuss it with two of the speakers Kyle Ridgeway and Kenny Venere on the Health Wealthy & Smart Podcast last week here and here.

As Myotherapy also requires the student to cover electrotherapy, taping and cupping, that should be a clear indication that ‘modalities’ do not define Physiotherapy. Read Kenny Venere’s take on modalities defining our profession here. With the exception of manipulations, the Myotherapy students I taught also covered all of the techniques in Chad Cook’s Orthopedic Manual Therapy text too. Many other professions use manual therapy and receive far more training in it than an entry-level Physiotherapist would, so to be defined by that alone is not an accurate reflection of our knowledge, skills or level of qualification…..and what happened to the exercise?

How did efficacy of manual therapy supersede exercise? I understand that some Physiotherapists choose to focus on manual therapy and may appear from the outside to be practicing like pseudo-Massage Therapists and Acupuncturists, but that’s not what I was trained to do.

I had been a Massage Therapist for five years before I started studying Physiotherapy. As a student Physiotherapist, I covered massage in one three-hour class – a Massage Therapists studies that for months. Taping only appeared as a voluntary add-on and wasn’t in the curriculum. Dry needling wasn’t covered at all, and the only manual therapy I received was based on Maitland principles and practices, and that was far from thorough.

See if you can tell what’s wrong with each of the following statements below:

  • Physiotherapy is a field of study that explores human movement and how it applies to physical activity pursuits, including: general fitness regimes, exercise for people with specific diseases and elite athlete performance.
  • Physiotherapists specialise in the design, implementation and evaluation of exercise and physical activity for healthy people. They provide programs for improving general health, the prevention of chronic diseases, health promotion and enhanced sports performance.
  • Physiotherapists specialise in the delivery of exercise, lifestyle and behaviour modification programs for the prevention and management of chronic diseases and injuries. Exercise physiologists provide support for physical activity programs and behaviour change for clients with conditions such as cardiovascular disease, diabetes, osteoporosis, mental health problems, cancer, arthritis, chronic obstructive pulmonary disease and many more.
  • Physiotherapists specialise in helping individual athletes or teams to improve their sporting performance through the use of scientific knowledge, methods and applications in the areas of physiology, biomechanics, psychology, and motor control and motor development.
  • A Physiotherapy curriculum will include core units of study covering: structural and functional anatomy, physiology, psychology, research methods, exercise physiology, biomechanics, exercise psychology, motor control, motor learning and skill acquisition, human growth, development and ageing, exercise, health and disease, health, fitness and performance assessment, exercise programming and prescription, health and nutrition and body composition

There’s nothing *wrong* with any of these statements, it’s just that none of them were written to describe Physiotherapy and what a Physiotherapist does. Those paragraphs have come straight out of the ESSA document describing Exercise Science, Exercise Physiology and Sports Science. I simply swapped the titles.

Can you see the challenge?!

I believe each of those statements accurately describe me and my role as a Physiotherapist, and therein lies the challenge I had with the GPs. All of the doctors appeared to be referring their patients for an exercise-based intervention to an AEP, not a Physiotherapist.

Physiotherapy has an image crisis.

Last year, a number of big names in Physiotherapy started a ‘Movement for Movement’ aimed at reducing the increasing scale of physical inactivity in modern society, intended to be a catalyst for change.

“This is an exciting start to a novel and international initiative which aims to reduce the growing global burden of inactivity-related disease. Our aim is to create a body of common knowledge, practice, resources and approaches so that healthcare and exercise professionals no longer work in silos with limited and often short-lived results.” Dr Roger Kerry (PhD)

Read about it here and here. It’s *supposed* to be everybody’s business, but as suggested, Physiotherapy is stuck in a silo of providing treatments which provide only limited and short-lived results. That’s low value healthcare.

Just yesterday the World Health Organisation published this global action plan to increase physical activity. The evidence tells us that people everywhere are less active than ever before, and the burden of chronic noncommunicable diseases rises unabated. An inactive world is unhealthier, uneconomic and unsustainable. If we spent less time squabbling over whose responsibility it is or who’s most appropriately qualified, we would soon realise that there are more than enough people to go around that need our help. Addressing exercise and using exercise in clinical practice is everyones responsibility.

“The incidence of chronic disease, in particular heart disease and diabetes, has prompted a need for prevention and treatment programs to reduce health care costs. Traditionally these programs were delivered by health and allied health professionals such as doctors, nurses, PHYSIOTHERAPISTS and osteopaths. Today, exercise therapy or treatment delivered in a clinical setting is an evidence-based practice recognised by Medicare under the banner of an accredited exercise physiologist (AEP).”

–ESSA

What happened!? I didn’t complete my Exercise Science Degree until the end of 2009. I didn’t see it happening then and it wasn’t until last week that the reality of how deeply entrenched we’ve become in the silo of ‘fixing people’. “People want to be fixed. They are always looking for the person who can fix them, or the procedure or the drug. The bad news here, or maybe it’s good news, is that you are not going to find someone who will fix you. You will be the fixer. You will be the one who develops the intensive exercise program that is going to allow you to escape from this.” We don’t “fix” people. People want magic, but they’re not going to get it.

The idea that I, or anyone else for that matter, can lay my hands on another human being and fundamentally change what’s going on inside them is absurd. Alongside ‘insanity’ in the Oxford English Dictionary perhaps it should read ‘See Physiotherapy’. Dianne Jacobs and Jason Silvernail talked about the shift away from being an ‘operator’ to becoming an ‘interactor’ here several years ago, with reference to Joel Bialosky’s work that investigated what’s actually believed to be happening with manual therapy.

“Your fancy hand jobs are not special in the therapeutic process, the way you relate to your client through your words and hand-holds are. Treatment outcomes, all of them, is not because of what you do but because of who you are. The number one determining factor for treatment outcomes is therapeutic alliance, aka, trust. This is what the evidence bores out. The better you prime a person’s expectations, leave them feeling heard, touch with them in a way that feels meaningful then you are likely to be of some use to them. But make no mistake about it, YOU ARE NOT doing anything to someone’s fascia. All that softening you feel under your hands, yeah, you can’t take credit for that. You can’t will that to happen. It was the client/brain that decided to change. It’s the client/brain that does all the heavy lifting and then alters its output.” Rey Allen

In the second episode of the Health Wealthy & Smart podcast linked above, Kenny Venere and Kyle Ridgeway cite a publication in the Physical Therapy Journal several years ago that surveyed use of therapeutic ultrasound among Board-Certified Orthopaedic Specialists; the <5% of clinicians held in the highest regard within the profession. 70-80% of responders used it, justifying its’ use based on mechanisms known not to be true. Kyle said he couldn’t imaging the cognitive barrier to giving up something like dry needling. With the time and cost involved in learning it, he said it’s no wonder that we’re failing to engage those providers in conversation.

As my GP-wife pointed out, the referral for ‘exercise’ is a no-brainer where the Physio operates from a consulting room and has no equipment to ‘do exercise’ with. How do you apply a meaningful load to a patient if you don’t have any? I imagine piggybacks are frowned upon. At least AEPs typically operate from facilities equipped to do exercise (therabands don’t count). Many GP practices have an in-house Physiotherapist who is stuck in a consulting room. Many patient experiences of private practice Physiotherapy revolve around the patient being horizontal on a treatment plinth. I won’t talk about the home exercise plans we give because by and large we know they’re not as effective as we would often like them to be…. Is it any wonder that the general perception of what we do is limited to that out-dated, largely ineffective approach?

There’s also the issue of under-dosed exercise. Even if exercise is being given, it needs to be “functional” (cough). This past week I’ve started helping a lady in her 70s who’s been doing Pilates for a long time. She’s independent and far from frail, but whatever she’s been doing hasn’t developed the strength in her legs to enable her to perform a box squat (that’s sit on a seat and stand up again), or comfortably transition from kneeling to standing without assistance. Surely that’s where we need to be starting; being able to manipulate our own body weight so we can use a toilet and get up from the floor if we fall.

I’ve had conversations with AEPs who believe that it’s not our place to be doing exercise either. It’s been suggested that I as a Physio should be referring on (to them) all patients who need ‘exercise’. I have a gym – specifically for exercise! I have 1.2 tons of kettlebells (a 68yr old woman with two prosthetic knees lifts our 56kg bell), a 7m rig, Olympic rings and parallettes. I even have two fit balls for the really advanced exercises (that’s a joke; the advanced part – I really do have the fit balls). I follow contemporary evidence in health and rehab and most of the people I work with probably don’t remember what my consulting rooms looks like; they walk onto the gym floor with the intent to stimulate some of the mechanotransduction Prof Karim Kahn talked about last week on Pain Reframed here.

Prof Kahn has previously encouraged Physiotherapists to embrace the term ‘mechanotherapy’ as a useful term to share with patients in the prescription of exercise to stimulate tissue repair, which is key to enabling patients to adopt exercise as treatment. Furthermore, as clinicians (the knowledge and skills for making clinical diagnoses arguably separate the Physiotherapist as a clinician from the Exercise Physiologist as practitioner), we *should* be better placed to determine the most appropriate exercise dosage in managing chronic connective tissue conditions – the Yin and the Yang of tissue homeostasis here.

Unfortunately, here in Australia, the policy-making fools within the private health insurance companies seem to be intent on making it difficult for us to follow the recommendations of the World Health Organisation and the leaders in our field like Dr Roger Kerry (PhD) and Prof Kahn, who actively promote mechanotherapy (exercise) in what we do with our patients.

This week I have seen discussion among Osteopaths and Physiotherapists in different forums whose businesses have been subject to random audit by health insurance companies. They have received demands for repayment of rebates paid for group ‘exercise’ sessions (the 560/561 codes) because general exercise in the absence of a pathological condition is not covered. The irony of that steaming pile of idiocy is that if I make a clinical diagnosis of non-specific low back pain citing limited core stability as the cause, provide therapeutic ultrasound, dry needling and apply some tape as treatment, and have the person attend clinical Pilates three times a week for six weeks as active rehab, it will be covered without question. Yet we are encouraged to keep those same people with NSLBP out of the medical system in the first place! Don’t take my word for it though: listen to Erik Meira and JW Matheson discuss it here.

Beyond the shadow of the enormous ugly silo, there are some shining lights working tirelessly to create a new path for our profession.

Dr Scotty Butcher is one of the brightest of them. Read his wonderful article ‘STRENGTH TRAINING WILL SAVE THE PHYSICAL THERAPY PROFESSION’ here.

“How do you “sell” your approach? How do you convince clients (and colleagues) that lifting heavy (properly) is good for them? In short…… how do we change a paradigm? We live it. We lift. We encourage our colleagues to lift. We prescribe lifting-based therapeutic movements. We make strength relevant to your client’s, and your colleague’s lives. Follow your passion, cut out a path, and know it’s going to be a damn hard one to do what you truly think is the right thing for your clients and patients.” Dr John Rusin (DPT)

“As a physical therapist, you must practice what you preach with strength training.” -Christina Nowak

“My advice to you is to remember that treatment philosophy is a choice. Remember that you’re not alone and just because these methods may not have been taught in PT [Physio] school, doesn’t mean they’re not tried and true. Remember that there is power in strength – if you lift, you’ve felt it. You know it in your soul. And that is the most important point. Believe in yourself, and your clients will too.” Dr Scotty Butcher (PhD)

What if someone has pain or is recovering from significant trauma – should they be exercising too? Most likely, yes. In relation to the shoulder joint, Greg Lehman wrote a great piece about developing ‘Comprehensive Capacity’ here. The same principles can be applied elsewhere.

What about resources? Well Roderick Henderson is running a live webinar here this weekend (May 27) on ‘Using Exercise to Develop Resilient Patients’. The information we need is everywhere if we choose to look for it, but we must first acknowledge if we’re in this gap where our experience and training hasn’t equipped us to safely and effectively build comprehensive capacity and patient  resilience. We’re all in this together (or should be) and it’s ok to reach out for help. We, and our patients, should all be living an active healthy life through exercise and physical activity. It’s our job to promote that and set an example.

I passionately believe that we need to be making a choice to step out of the box we’ve put ourselves in to. If we follow the evidence and chose to make exercise and mechanotherapy our primary intervention, everyone will be better off.

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