Physiotherapy Rehabilitated: Change

You may remember the final part of my Pain series had proposed an alternative approach to physiotherapy. That Post had to be removed due to circumstances beyond my control, infringement reasons, which I still am at a loss about. I had intended to look at the current management approaches for persistent pain, which I decided against. Why? Well I explained that teaching you to suck eggs was not the way. Instead investigating the holistic approach that physiotherapy could harness is more appropriate as they can have an impact on pain experiences. So I  share my thoughts on physiotherapy and medicine and how new evidence is paving to what I believe could be a more refined direction for Physiotherapy……

I will start by saying there are a lot of blogs/websites out there that all talk about approaches to pain management, so I complied a short list of recommended blog/websites at the bottom of this post.

The emergence of pain science and neuroscience is creating a paradigm shift from the biomedical model to a biopsychosocial approach. Pain cannot be discussed or treated through dualism, although that is how many of us manage it. We take a pill as we understand that it helps our pain as we are lead to believe by several sources – medical professionals, the media, television, etc. We use a passive treatment to block the signals that may contribute to pain but why do we persist in taking them when they do not resolve the issue. Why use a passive process to facilitate an active one? I know I know it’s easy to pop a pill, but let me share a revelation with you. In the United States alone, in the last 10 years, there has been a significant increase in pain-killing medication prescription for persistent pain problems such as low back pain, headaches and other persistent pain states (reference). This has resulted in medication abuse concurrently creating an increase in overdose numbers. Brainman explains:

Studies have shown that pain killing medication is no better than placebo when treating something like low back pain highlighting that a one size fits all approach to pain treatment is not efficacious (reference, reference). When you step into the realms of the Brain, pain is many things; contextual, implicit, attentional, physical, behavioral, Pain treatment cannot be considered as something separate to treat. Its integration is part of every aspect of overall health and well-being and there are multi-factorial aspects to pain. If medicines philosophy is to preserve life, do we want to prolong suffering as well? Therefore we need to look beyond medical care, re-conceptualise our thinking. I am not suggesting we become ignorant of medicine. It has made some amazing discoveries and performed some revolutionary advances. However this has lead to dependency on an overstretched and inefficient medical system. There is much more that we can do to empower ourselves. Medicine takes away that responsibility of self-empowerment. The term preserve life already casts a shadow of removal of ownership away from the individual.  Medicine has allowed us to become complacent and lazy as we believe it will have the answers.  This is contextual and pertinent to my area of healthcare I cannot speak for other areas.

In order to grasp this series of posts I feel it is pertinent to point out the alarming rate of evidence that is published every day/week/month that influences our clinical practice. The subsequent 5 posts are heavily researched, ground-breaking, exciting and under constant scrutiny. So although this is something healthcare has always advocated it has never encouraged independence it has created dependency. This is more important since the emergence of neuroscience and pain science. Gone are the days of just pushing on someones back and rubbing out scar tissue. Clinicians are having a tough time keeping up with change, some don’t like change at all!

What I will share with you are my discoveries and thoughts on why physiotherapy needs to be identifying the aspects of overall health asking alternative questions that consider more of a holistic approach to pain management and overall health and that interdisciplinary team working is fundamental to the future of front line healthcare. I am fearful that physiotherapy is sitting back and allowing other professionals to come in and do our work for us at a risk of loosing our identity. Dave Nicholls eloquently explained this in his post on connectivity and physiotherapy (here). There are challenges such as persistent pain, obesity, diabetes at epidemic proportions that are associated with a host of other problems including mental health issues, cardio-vascular disease, financial constraints and social isolation all continuing to grow at unprecedented rates and our current system is failing us. I believe a lot of these issues can be addressed with the consolidation of the 5 areas I will talk about in the coming weeks.

This blog post was not intended to get all philosophical about physio, however I can’t talk about the future of physio without getting all philosophical, it is fundamental to our professional existence. So if you will permit me, I will now have a wee rant.

A wee rant….

Historically (may make a few heads roll with this!!) physio’s have jumped on bandwagons as nicely pointed out by Adam Meakins here, and I wonder why that is? Is it insecurity in our profession? Is it our need to prove ourselves? Is it to stamp out Dogma? Do we actually know ourselves what we do? If we are not jumping on pain management; and I love pain management we are releasing trigger points or using fancy coloured tape or performing the latest and greatest manual therapy technique or a new gadget that you can sit on to challenge your balance.  The latest one looks discerningly phalic! (Bronnie Thomson’s blog explains!) We have always advocated exercise yes but we have jumped onto individual treatments a lot such as Electrotherapy (little bit of exercise), Manual Therapy (little bit of exercise) Acupuncture (little bit of exercise) and other fancy treatment techniques (little bit of exercise) that are all…..well….not really providing the long term outcomes we are so desperately looking for (reference, reference, reference, reference). Exercise has always appeared to come last despite the fact that a lot of evidence suggests it’s just as good as the passive treatments and it has a host of other health benefits. (reference, reference, reference, reference, reference).

In fact at physiotherapy school exercise was covered in, I recall, one or two seminars and when I joined the NHS the majority of the time I used exercises as part of my treatment, the irony!!?? I wonder if we had embraced and understood exercise better would we have consolidated our knowledge of manual therapies and exercise = clinical reasoning. I guess the great thing that we have is our ability to critically think, to clinically reason and use our diagnostic skills, which should set us apart from the crowd i.e. strength & conditioning coaches, Personal Trainers etc. However it seems it doesn’t and there is a fine line where those boundaries are being crossed at the potential risk of causing harm to patients and as previously explained losing our identity. Before you all jump at me saying I have a good relationship with the aforementioned, I salute you, I hope you know it’s reciprocal and I’m not talking about you per se I’m talking about the standing of our profession. So why do I think this? Possible reasons are because of dogma and reductionism within medicine which has filtered into our profession or perhaps not truly identifying our place (The CynicalPT does a good job of explaining)….. So indirectly I’m saying maybe it’s our fault… perhaps it is insecurity within our profession. Of course I am open to scrutiny and to be told what on earth am I talking about?? It generates discussion.

So I propose this….

Physiotherapists working as triage providers to specialties in healthcare.  Physiotherapists would still have their special interests, their extended scopes, the evidence that I will highlight in the following post suggests there is more scope for specialism and diversity. As front line practitioners physiotherapists can be and offer so much more. We are one of the few professions that are front-line, have a direct link within the medical system, is focused towards health promotion and has such a close association with GPs. We could facilitate and consolidate their workload.

GPs get a rough time, So let’s get back to my thoughts on best management and where we can go in terms of providing a more holistic approach to healthcare. Significant advances in health science are identifying strong evidence to support specific approaches to pain management from an individual perspective. These approaches have been around for years and are a large part of our everyday lives. 5 components that encompass total health. This includes exercise, diet, sleep, mindfulness and stress success. Those of you that are already doing this, great! Keep it going! What I do ask is why then are the most obvious things the hardest to change?

Thanks again for reading

TNP

 

Recommended websites for learning about Pain

www.bodyinmind.org

www.noijam.com

www.pain-ed.com

Blogs to learn about pain/health/philosophy

www.healthskills.wordpress.com

http://breakingmuscle.com/

http://criticalphysio.me/

Recommended Podcasts for everything related to Health

www.chewshealth.co.uk/

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7 thoughts on “Physiotherapy Rehabilitated: Change

  1. Thanks so much for including my blog in your list of places to visit on the interwebs. This list is one of those things I’ve bookmarked for myself for when I’m getting that sense I’m shouting into a hurricane and no-one else is listening. There IS a rising number of people who get it – and isn’t it cool that because of this, people with pain will ultimately benefit. Yes!! that’s why we do it, isn’t it?!!

    Liked by 2 people

  2. Well! That was quote the post! SO much good information there. I have been to MANY PT’s over the years and must say they tend to just treat the injury. Many have no training and/or time to deal with anything other than the pain that brings you in to the office in the first place. I must say, I have never met a PT that I have not liked. They are a great bunch. I have a QUESTION. 🙂 Hypertonic pelvic floors! What advice regarding exercise can you share about a pelvic floor that is tight, and abdominals muscles are firing as well. Again, fantastic article. It is going to take at least one more read to absorb such great information.

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    1. Hi
      Thats a difficult question as I would require a working understanding of why you think (i assume it is you) a pelvic floor would be tight and abdominal muscles firing too?
      Are you asking if they should fire together or independently and want an exercise to facilitate either?

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      1. Yes, it is moi. I am trying to workout more than just walking. I have a hypertonic pelvic floor with every muscle tight (at the moment) and my abdominals as soon as I remotely work them, even doing leg raises by the next day are so full of trigger points and hurt – and then my pelvic region flares and the pain begins. My question has been lately, how does a person exercise during a pelvic floor and abdominal flare up. My PT is fabulous at working at my TP’s but I know I need to see someone that specializes in exercise but all my money goes to the wonderful PT that deals with my TP’s. I have been searching the internet and reading books, but have not found an answer yet that is working. I have been doing fascia rolling on my own, and TP on my own as well (Jill Miller Roll Model) – as well as stretches from Amy Stein book on Pelvic Pain. Fabulous at reducing it, but I want to find a way to work out my arms and legs without flaring everything. I see others in different pelvic pain groups I am in that feel like they are just going to give up – that as soon as they start to do anything but walk, they are in a flare up. We need help. 🙂

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      2. I have spoken to a physio colleague of mine who is a specialist in pelvic health and she will be commenting on your comment soon as a hypertonic pelvic floor is not something I commonly see or have come across.
        I would add that as part of your rehab exercise should be integrated into it as TP release has a very short term effect.
        I would be keen to know who diagnosed you with a hypertonic pelvic floor and what the reasoning behind it is? Is it a result of pregnancy? Or some other issue?
        This is a sensitive issue for some so perhaps a private email conversation with my colleague would be of help to you.

        Liked by 1 person

  3. Hi There!

    It sounds like you’ve been lucky enough to find some clever PTs who have helped you address some of your symptoms, but that you’ve not yet figured out the reason your poor pelvic floor is overworking! The pelvic floor is the floor of the core, and there is a lot of cooperation that is supposed to be happening between the abs and the pelvic floor. The SHOULD turn on when you do arms and leg exercises, but you’re correct in noticing that it should NOT cause a flare up of any kind.
    Have you discussed with your physios the fact when you use your muscles they flare up? It sounds like you have loads of ways to help deal with flare ups, but no way to avoid them… More work needs to be done, and my guess is that it is not more fascia rolling and trigger point work. Have a chat with your physio and see what they say!

    Also, a great book on pelvic pain, ‘Why Pelvic Pain Hurts’, is a great resource that will talk about other contributors to your bits not working right. (Full disclosure, my business partner is one of the authors, but that doesn’t change the fact it’s a great resource!!)

    There is help available!!!!

    Cheers,
    Sarah

    Like

    1. Thanks Sarah, the book is not offered in Canada I see. As soon as it comes out in Kindle or E-book, I will grab a copy. The reviews look great! My PT is amazing – Her whole practice is pelvic pain, and because they are so few like her, she is in hot demand. After she works on my abdominal and inter-vaginal trigger points, the relief is amazing. And we have spoken about my abs. And she would rather I just lay off working out for awhile and just let them heal. I would a) like to figure out why I tend to hold pain in my muscles more b) what exercises can be done that don’t totally engage the core c) if your floor is super tight – what key ways can you reduce this, and especially how to strengthen my various muscles groups and relax them afterwards.

      I just received a book on Somatic exercises and will look into that more. I started a website and have been documenting the things that I have been learning in hopes of helping others. I hope to be a clearing house of information dedicated to helping others in pelvic floor pain. These past 4 years have been awful. You really do think you are going crazy with the pain, and General Practitioners just want to give you anti-depressants. I will not stop until I find various self-help methods for the men, women and children that “hurt down there” every day. It seems that what works for one, does not work for all – we are just so different! 🙂 Thanks for listening and your advice. I surely appreciate it!

      Like

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