InDepth

Physiotherapy - what is it?

It's not what it used to be.

What is physiotherapy?

 

Things change all the time. The technology, philosophy, science, and of course, medicine.

So where is physiotherapy right now, in the beginning of 2018?

 

There is a persistent definition of physiotherapy that is a hangover from how the profession cemented itself a few decades ago. However that definition is a concept of the profession that is now narrow in scope and self-limiting. Not to mention outdated with the current literature. 

If you look at Wikipedia, Physiotherapy or physical therapy is written as a

“profession that by using mechanical force and movements (Bio-mechanics or Kinesiology), Manual therapy, exercise therapy, and electrotherapy, remediates impairments and promotes mobility and function”.

That is pretty much straight out of 1980’s; it completely ignores the progression of physiotherapy profession, especially over the last ten years, that includes:

 

 

1) Biopsychosocial framework (1, 2)

2) Change of focus from impairment to disability (3-5)

3) Disassociation of relationship between structure and disability (6-9)

4) Definition of pain as according to IASP (Click here)

5) Realisation of importance of placebo response and its composition (10-12)

6) Increasing lack of clinical relevance of electrotherapy (13-17)

7) Progression on understanding of neurophysiology and the role of physiotherapy within it (18-23)

 

 

There are more of course, integration of exercise therapy springs to mind. Physiotherapy, like most facets of medicine, is a constantly-changing landscape.

So this is our definition of physiotherapy as in 2018:

 

Physiotherapy or physical therapy is:

 

“Clinical practice to influence a physical condition or an experience of such condition by interventions that are not pharmaceutical or surgical.”

The key words or phrases to note in this definition are:

"Clinical"

Physiotherapy is a clinically-reasoned, hypothesis-generating process. In order this to be achieved, physiotherapists must have clinical knowledge and ability to use the knowledge.

"to influence"

The purpose of physiotherapy or all medical practices that I can think of, is to influence. Hopefully positively. Now this is a big subject, as the methods of influence (or methods of treatment) is arguably the most critical aspect (and also most criticised) in physiotherapy practice.

"physical condition or an experience of such condition"

This is a massive change. Physiotherapy used to be all about simply influencing physical aspects in order to make physical changes in patients. It made perfect sense of course. But the body is more complicated than that.

Now, we are realising that we often do NOT influence anything physically, but we’re changing the patient’s experience of the conditions. Much of the fantastic gains that we might have delivered as physiotherapy clinicians, may have not been because we “loosened the joints or relaxed the muscles”, “the core got stronger” or “the pelvis realigned”, but because we positively influenced something else that is not as tangible but just as real.

(Of course there are times when I DO believe that "loosening joints or muscles" or "core strengthening" or other actual physical changes can be influenced AND are critical to patient's outcome. Just not as much as I used to think) 

This encompasses all the progressions that I mentioned just earlier: biopsychosocial framework, disability model and its lack relationship with impairment, our greater understanding about pain and neurophysiology, and acknowledgement of placebo response.

 

Looking at physiotherapy from this viewpoint shifts the goalpost quite a bit. And it is hugely challenging, especially those who have practiced in a certain way for many years.

However here is great news: developing as a physiotherapist is not about ditching one vehicle and jumping onto another. It’s more about making small modifications to what you already have by learning and integrating new ideas. So you may still do certain treatment but the way you think becomes different, then the way you DO will begin to be different, then you learn more and absorb more, then you’ll educate patients differently, teach exercises differently, set different goals. Gradually you’ll become a different but better practitioner. And EVERYONE can become better. Everyone NEEDS to get better.

Because physiotherapy can become so much deeper than how many of us are already practicing. We’ll help patients more effectively, and we’ll become more fulfilled as human beings. So I encourage you to be inquisitive, embrace the uncertainty and complexity of what we’re trying to do and enjoy the journey of discovery and genuine connection with patients.

 

 

References

1. Main CJ, Sullivan MJL, Watson PJ. Models of pain and disability. Pain Mangement, Practical applications of the biopsychosocial perspective in clinical and occupational settings. 2nd ed. Edinburgh: Churchill Livingstone Elsevier; 2008. p. 3-27.

2. Borrell-Carrio F, Suchman AL, Epstein RM. The biopsychosocial model 25 years later: principles, practice, and scientific inquiry. Ann Fam Med. 2004;2(6):576-82.

3. Linton SJ, Nicholas MK. After assessment, then what? Integrated findings for successful case formulation and treatment tailoring. In: Breivik H, Campbell WI, Nicholas MK, editors. Clinical Pain Management: Practice and Procedures. 2nd ed: CRC Press; 2008. p. 95-106.

4. Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F, et al. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006;15 Suppl 2:S192-300.

5. Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J, Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J. 2010;19(12):2075-94.

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7. Rudy IS, Poulos A, Owen L, Batters A, Kieliszek K, Willox J, et al. The correlation of radiographic findings and patient symptomatology in cervical degenerative joint disease: a cross-sectional study. Chiropr Man Therap. 2015;23:9.

8. Schwartzberg R, Reuss BL, Burkhart BG, Butterfield M, Wu JY, McLean KW. High Prevalence of Superior Labral Tears Diagnosed by MRI in Middle-Aged Patients With Asymptomatic Shoulders. Orthop J Sports Med. 2016;4(1):2325967115623212.

9. Panagopoulos J, Hush J, Steffens D, Hancock MJ. Do MRI Findings Change Over a Period of Up to 1 Year in Patients With Low Back Pain and/or Sciatica?: A Systematic Review. Spine (Phila Pa 1976). 2017;42(7):504-12.

10. Schoth DE, Liossi C. Biased interpretation of ambiguous information in patients with chronic pain: A systematic review and meta-analysis of current studies. Health Psychol. 2016;35(9):944-56.

11. Vase L, Robinson ME, Verne NG, Price DD. The contributions of suggestion, desire, and expectation to placebo effects in irritable bowel syndrome patients. Pain. 2003;105(1):17-25.

12. Moerman DE, Jonas WB. Deconstructing the Placebo Effect and Finding the Meaning Response. Ann Intern Med. 2002;136:471-6.

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14. Feger MA, Goetschius J, Love H, Saliba SA, Hertel J. Electrical stimulation as a treatment intervention to improve function, edema or pain following acute lateral ankle sprains: A systematic review. Phys Ther Sport. 2015;16(4):361-9.

15. Kroeling P, Gross A, Graham N, Burnie SJ, Szeto G, Goldsmith CH, et al. Electrotherapy for neck pain. Cochrane Database Syst Rev. 2013(8):CD004251.

16. Page MJ, Green S, Mrocki MA, Surace SJ, Deitch J, McBain B, et al. Electrotherapy modalities for rotator cuff disease. Cochrane Database Syst Rev. 2016(6):CD012225.

17. Rutjes AW, Nuesch E, Sterchi R, Juni P. Therapeutic ultrasound for osteoarthritis of the knee or hip. Cochrane Database Syst Rev. 2010(1):CD003132.

18. Garland EL. Pain processing in the human nervous system: a selective review of nociceptive and biobehavioral pathways. Prim Care. 2012;39(3):561-71.

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22. Louw A, Zimney K, Puentedura EJ, Diener I. The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiother Theory Pract. 2016;32(5):332-55.

23. Moseley L. Combined physiotherapy and education is efficacious for chronic low back pain. Australian Journal of Physiotherapy. 2002;48(4):297-302.