Why is it that we do physiotherapy in this way?

‘Oh, I’ve been shaking
I love it when you go crazy
You take all my inhibitions
Creativity, there’s nothing holding me back
You take me places that tear up my reputation
Manipulate my decisions
Creativity, there’s nothing holding me back
There’s nothing holding me back
There’s nothing holding me back’

 Adapted from Shawn Mendes, There’s Nothing Holdin’ Me Back, (2016)

Historically, physiotherapy adopted a biomedical/biomechanical view of the body. A model that is reductive, separating the body into its respective parts. A model that is explicitly associated with the metaphor “body as machine”. Ultimately, the biomedical/biomechanical model played an important role in the professions legitimacy (Nicholls & Gibson, 2010). Moreover, professional boards, health authorities and clinical departments recognised parallels between the work of physiotherapists and other clinicians such as orthopaedic surgeons. This recognition lead to the development of specialist trained and extended roles, establishing a hierarchy of knowledge and expertise so to recognize those clinicians that excelled in their field (Daker-White et al., 1999).

Interestingly, much of what physiotherapy bases it’s legacy on, the biomechanical model, has been brought into question by the ever increasing evidence base. In addition, the evidence base has also questioned much of the ideology of the biomedical model. Couple that with the changing needs of society, increasing government pressure on healthcare reform, increasing rates of disability in areas such as musculoskeletal conditions, increasing financial strain on healthcare budgets I think it is a reasonable question to ask:

“Why is it that we do physiotherapy in this way?”

Like all professionals, from all walks of life, be it chefs, doctors or pilots, physiotherapists follow professional guidelines, invest time and money in development, use an evidence based approach and gain experience over years of commitment to their career.

Physiotherapy’s affinity to medicine since the early 1900s meant the profession aligned itself closely through subjects of anatomy, physiology and pathology. Physiotherapists identified as the professionals in understanding movement, adopting a biomechanical approach as their model of choice (Nicholls & Gibson, 2010). Through understanding faulty movement patterns or postures, physiotherapists legitimised their practice by inferring these issues lead to pain and injury, which as we know lack validity (Lederman, 2010; O’Sullivan, Smith, Beales, & Straker, 2011).

Adopting a biomedical / biomechanical perspective meant physiotherapists could specialize in specific areas of the body – spine, knee, shoulder. Yet, the principles of biomechanics have become somewhat warped with claims of “optimal body alignment” will lead to optimal body movement and minimize pain and injury. This is not supported by the evidence (Lederman, 2010). Furthermore, the increasing evidence base in pain, biomechanics and even placebo research refutes much of the theory that legitimised the inception of (MSK) physiotherapy. In addition, despite being the gold standard, the effectiveness of randomised controlled trials as a method of research to inform practice, lacks external validity. Thus, the noose appears to be tightening around the professions neck.

Is there a problem with this?

Experts might say no. They are comfortable with their clinical knowledge, have confidence in their area of interest. They have worked hard to get where they are, have learned from experts before them, perhaps even conducted research in their area of clinical interest.

Perhaps the problem is experts know too much?

What am I getting at? Interestingly, research has shown that healthcare professionals with experience and who feel like experts are less likely to react to negative news about a particular practice they have specialised in. Meaning they would be less likely to adapt their practice, despite what the evidence might suggest.  Similarly, individuals who are around peers with more experience are more likely to imitate and side with the choice of the perceived expert (Staats, Diwas, & Gino, 2018).

This may come down to the specific training and reasoning processes that healthcare professionals have developed through their education. Biomedical reasoning is inductive, meaning it follows a particular course of reasoning from obtaining clinical data from say a subjective history to ascertain a diagnosis.  Specialists or experts tend to favour the use of this method as it provides greater odds of diagnostic success (Coderre, Mandin, Harasym, & Fick, 2003). It is reasonable to say that attempting to achieve diagnostic success has not exactly lead to the best in healthcare outcomes (Deyo, Mirza, Turner, & Martin, 2009).

When faced with problems that we believe we’ve encountered in the past, thinking we have the knowledge to solve the problem, we feel a sense of comfort and confidence. This feeling can lead us to approach situations mindlessly rather than thoughtfully. We adopt a particular type of diagnostic reasoning looking for specific patterns to confirm our suspicions. This is not wrong but we may overlook important and necessary information. Remember we are dealing with people and people are all different in many ways. I have written before here about my feelings on using an alternative approach when assessing and reasoning.

So ,how would I answer the question? I recognize the need for experts. Experts are considered to have experience in areas of clinical interest. However, it is how much of an open mind experts have towards experimentation, stepping away from what they have devoted their entire clinical practice upon. Do they stick within their comfort zone of expertise or are they open to experimentation? Do they break the rules?

A recent twitter conversation appears to exemplify this legitimisation issue that continues to pervade the profession. A study by Rosedale et al., (2019) exploring the prevalence of Extremity Pain of Spinal Source (EXPOSS), wanted to investigate the proportion of patients that present with isolated extremity pain who have a spinal source of symptoms and then evaluate the response to spinal intervention. A number of points were made on social media. Of particular interest was the bias by the group to prove their outcome.  The research group adopted a particular method of approach, a classification system that has been embedded within (MSK) physiotherapy since the 1980s. Much of the conversation on social media around topics of this classification system are frequently defended by clinicians that are trained in the method. Comments often revolve around clinicians not being trained in the method and therefore do not understand or that clinicians that have limited experience in the method are criticised. Interestingly, evidence has suggested that the method is no better than a “wait and see” approach (Takasaki & May, 2014) or that it is no better than placebo (Garcia et al., 2018) and that there is little difference in treatment delivery and outcomes irrespective of the level of experience (Deutscher, Werneke, Gottlieb, Fritz, & Resnik, 2014).

I want to be clear here, I am not questioning the method, as this has been done by Louis Gifford here, I am querying the level of confidence that clinicians, who practice the method, place over other methods or approaches in the treatment of muscloskeletal conditions.

So, back to breaking the rules. If we are open to experimentation we could be asking ourselves, every time we step into the clinic, “what can I learn?”

Or

“How could I approach a back problem or knee problem from a different perspective?” Perhaps a humanistic approach rather than a diagnostic or deductive approach?

An important message

I am not telling you to be reckless. There are necessary steps that we need to take in our day to day clinical practice such as clearing red flags or appropriately reasoning referrals. The type of rule breaking I am talking about are those that are constructive, not rule breaking that is destructive.  Constructive rule breaking may be uncomfortable but it is something that can lead to positive change (Gino, 2018). Consider the notion of getting comfortable with being uncomfortable. This can spark creativity in our ways of thinking and delivering physiotherapy.

Constructive rule breaking might be:

Changing the order of your assessment, consistently asking yourself reflective questions such as, “why is this person presenting to me in this way at this time?” Getting out of the clinic, going surfing with your back pain patient, organising a beach clean up or rubbish run with your patients, engaging in alternative communication strategies, using music or art in your clinical notes as a form of narrative expression, climbing a tree, thinking about the limitations of classification systems or frameworks.

To finish

As we gain experience, we gain skills and knowledge and can become blinded by believing we have the right answer. We can forget to stay humble or forget to consider what is left to learn, rather than what it is we already know..

I am sure there are times in our careers where we felt like the expert we got stuck and were unable to come up with a solution. This feeling of being stuck may mean we feel like a failure.. Being humble and accepting the limits of our expertise, adopting new ways of working such as shared decision making or collaborative approaches with patients, respecting that they are experts in their bodies, viewing problems through different lenses perhaps a social lens or an environmental lens could mean that we look at the problem from a very different perspective, which may ultimately present us with a solution.

So, lets break free of the chains of traditional physiotherapy conformity, be a bit rebellious, expand your mind to new and innovative ways of working and thinking and ask yourself

“How could I do physiotherapy in a different way?”

Thanks for having a read.

TNP

P.S. If this blog didn’t spark any creativity, at least listen to Shawn Mendes, he might!

References

Coderre, S., Mandin, H., Harasym, P. H., & Fick, G. H. (2003). Diagnostic reasoning strategies and diagnostic success. Medical Education, 37(8), 695–703. https://doi.org/10.1046/j.1365-2923.2003.01577.x

Daker-White, G., Carr, A. J., Harvey, I., Woolhead, G., Bannister, G., Nelson, I., & Kammerling, M. (1999). A randomised controlled trial. Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments. Journal of Epidemiology and Community Health, 53(10), 643–650. https://doi.org/10.1136/jech.53.10.643

Deutscher, D., Werneke, M. W., Gottlieb, D., Fritz, J. M., & Resnik, L. (2014). Physical therapists’ level of McKenzie education, functional outcomes, and utilization in patients with low back pain. Journal of Orthopaedic and Sports Physical Therapy, 44(12), 925–936. https://doi.org/10.2519/jospt.2014.5272

Deyo, R. a, Mirza, S. K., Turner, J. a, & Martin, B. I. (2009). Overtreating chronic back pain: time to back off? Journal of the American Board of Family Medicine : JABFM, 22(1), 62–68. https://doi.org/10.3122/jabfm.2009.01.080102

Garcia, A. N., Costa, L. D. C. M., Hancock, M. J., De Souza, F. S., Gomes, G. V. F. D. O., Almeida, M. O. De, & Costa, L. O. P. (2018). McKenzie Method of Mechanical Diagnosis and Therapy was slightly more effective than placebo for pain, but not for disability, in patients with chronic non-specific low back pain: A randomised placebo controlled trial with short and longer term follow-up. British Journal of Sports Medicine, 52(9), 594–598. https://doi.org/10.1136/bjsports-2016-097327

Gino, F (2018). Rebel Talent: Why it pays to break the rules at work and in life. Dey Street Books; 1 edition

Lederman, E. (2010). The fall of the postural–structural–biomechanical model in manual and physical therapies: Exemplified by lower back pain. CPDO Online Journal, 1–14.

Nicholls, D. A., & Gibson, B. E. (2010). The body and physiotherapy. Physiotherapy Theory and Practice, 26(8), 497–509. https://doi.org/10.3109/09593981003710316

O’Sullivan, P. B., Smith, A. J., Beales, D. J., & Straker, L. M. (2011). Association of Biopsychosocial Factors With Degree of Slump in Sitting Posture and Self-Report of Back Pain in Adolescents: A Cross-Sectional Study. Physical Therapy, 91(4), 470–483. https://doi.org/10.2522/ptj.20100160

Rosedale, R., Rastogi, R., Kidd, J., Lynch, G., Supp, G., & Robbins, S. M. (2019). A study exploring the prevalence of Extremity Pain of Spinal Source (EXPOSS). Journal of Manual & Manipulative Therapy. https://doi.org/10.1080/10669817.2019.1661706

Rothwell, P. M. (2007). Assessment of the external validity of randomised controlled trials. Treating Individuals: From Randomised Trials to Personalised Medicine. Spain: Elsevier,365, 61–82. Retrieved from http://books.google.com/books?hl=en&lr=&id=aHfBF8GoL8UC&oi=fnd&pg=PA61&dq=%22also+be+relevant+to+a+definable+group+of+patients+in%22+%22Council,46,47+makes+virtually+no+mention+of%22+%22How+these+factors+are+taken+into+account%22+%22space+to+external%22+&o

Staats, B. R., Diwas, S. K., & Gino, F. (2018). Maintaining Beliefs in the Face of Negative News: The Moderating Role of Experience. Management Science, 64(2), 804–824. https://doi.org/10.1287/mnsc.2016.2640

Takasaki, H., & May, S. (2014). Mechanical Diagnosis and Therapy has similar effects on pain and disability as “wait and see” and other approaches in people with neck pain: A systematicreview. Journal of Physiotherapy, 60(2), 78–84. https://doi.org/10.1016/j.jphys.2014.05.006