I read this paper very recently and it challenged my assumptions hugely about patients with chronic pain, or rather persistent pain as it’s now preferred to be called. My assumption was that patients with persistent pain would naturally have a reduction in their physical activity levels and so suffer some level of physical deconditioning over time in terms of reduced muscle strength and/or increased weight and body fat gains.
Not so it seems, so I posted it out onto the twitter-sphere expressing my surprise and learning experience and it soon got some comments. First was from some about how I shouldn’t assume anything, and yes they’re right, I shouldn’t, but I do, it’s called being human, so shut the hell up, you’re not being helpful.
But more interestingly I got comments from others who tell me physio’s need to recognise and understand that many patients with persistent pain don’t have ANY reduction in their physical activity levels, or ANY loss of their activities, nor suffer from ANY lack of physical conditioning.
They went on to tell me how they see patients with persistent pain who have very high activity levels and have NO movement or functional limitations just pain. Some also went onto tell me that exercise or movement interventions should not be used by physios in these cases.
Well I am really surprised by these comments, firstly because in 15 years as a physio I can not think of a single patient who I have seen in pain who did not have or tell me they have some issue or loss of a movement, or function.
There are of course some who come to see me for advice on injury prevention or strength and conditioning but these tend to be one off consultations, and they certainly don’t have persistant pain.
I am also really surprised that some physios think physiotherapy doesn’t have to include exercise or movement interventions.
This is something I hugely disagree with. Of course exercise and movement interventions should NOT be used in isolation, but movement or exercise therapy is THE foundation treatment we as physiotherapists should use, it’s our primary role, it’s in our bloody job title for christ sake… Physical Therapy.
So I questioned this point further on social media, asking for more opinions on when people thought the role of a physiotherapist stops being a physiotherapist.
As far as I am concered when a patients tells me there are no physical impairments, or no functional limitations, and exercise and movement interventions do not help, then my job as a physiotherapist is done.
I say this because a physiotherapists role is to increase, improve, and restore movement and function of an individual with pain or a disability. This is reflected in the UK chartered society of physiotherapists statement on ‘what is physiotherapy’ here.
Many physiotherapy departments are simply struggling with the work loads they have in just dealing with the patients with physical disability and pain limiting their activities. So is it fair to ask physios to help those WITHOUT movement or physical issues as well? The question also begs that if there are no physical issues for a patient, what the hell does a physiotherapist do in a session with a patient?
When does a physio stop being a physio and start becoming a psychologist?
Now of course many physiotherapists, including myself, are trained in some psychological and other non physical interventions to help patients over come pain and other life changing events. Most physios have techniques to help motivate, encourage and reconceptulise patients pain. But these interventions are never used in isolation, just as any intervention even exercise should not be used in isolation.
Psychological methods are to be used by physiotherapists to help supplement exercise and movement interventions, and visa versa, exercise interventions help supplement psychological interventions.
What gives some physiotherapists the arrogant belief that they are the best healthcare professionals to treat patients with persistent pain using only psychological interventions?
Physiotherapists first need to get their shit together on improving ways to restore and improve movement, physical impairment and disability of those in pain before worrying about helping others who are coping with pain.
Now, before you all go nuts in the comments section, I am acutely aware that there is a very fine line, if there is one at all, between physical and psychological problems and there interventions. I am not implying that physical interventions are not psychological, nor that psychological ones are not physical. The physical and psychological are intimately and inextricably linked!
Nor am I saying that we should ignore or abandon our psychological techniques to help those with physical impairments, or that pschological interventions don’t work or help people with pain as some often try to claim I am suggestting. These are tiresome false dichotomy’s and they piss me off immensely when people try to twist my views like this. So again, shut the hell up, you’re not helping.
Cognitive Behavioural Therapy; Acceptance and Commitment Therapy; Mindfulness; Motivational Interviewing, etc etc… the list is long of different methods many physios, and again I include myself here, can successfully use in their management of patients with pain, but, and this is the ass grabbing, elephant in the room point I want to stress again, they are all used with exercise or movement interventions… TOO GET PATIENTS MOVING MORE!
So physio’s, be physio’s. Focus on our primary role, what our job title states, to get people physically moving more! That’s more comfortably, more efficiently, more often. Of course use psychological methods and interventions, but lets not use them in isolation, and let’s focus on those not coping with life in pain first before we look to help those who are.
As always thanks for reading
PS: Hat tip to Alan Taylor @TaylorAlanJ for the inspiration for this blog!