Physios are too soft…

Warning: This blog may cause offence.

So you might be thinking this will be about recent online events where some physios took offence at a word I used in a tweet. And in a way it is, simply put some physios are too soft and way too easily offended at things they read or hear. But this is actually more about how many physios are too soft, too scared, and too afraid of pain. This is about how I think many physios need to toughen up both professionally and personally.

So recent online events have once again highlighted to me how this profession is full of hypocrisy and contradiction. It seems that those who claim to be compassionate and understanding clinicians, are quick to rebuke and chastise others who make genuine mistakes. It appears that those who claim to be rationale and intelligent thinkers, often fall foul of logical fallacies and errors in critical thinking. Those who claim to be keen for progress and change, are often quick to attack and shut down anyone who questions them or their ideas. And finally those who bang on about disliking self promotion and egos appear to promote themselves and their courses more than anyone else.

However, the biggest contradiction with many physios is in how they manage people in pain. Many physios say they now understand and realise that pain and structural issues are poorly correlated, how pain doesn’t equal damage, hurt doesn’t mean harm, and sore can be safe. Yet despite saying this they still act the complete opposite always looking to reduce or remove pain with manual therapy, tapes, machines, and other shitty stuff, they also tell patients to stop doing tasks or activities that cause pain, and wouldn’t even contemplate getting patient to do an exercise or task that hurts.

What’s the issue with physios and pain?

Why do so many physios say pain is OK and safe one second, and then in the next breath do the exact opposite by telling patients to avoid things that hurt? Well I believe that despite talking a good game many physios don’t actually believe that it is OK to ask patients to do things that hurt, nor do I believe that many feel confident or comfortable letting pain continue or increase in those they see. To put it bluntly many physios are shit scared of pain existing or increasing in their patients and to paraphrase Pete O’Sullivan on his recent workshop in London…

if physios are scared of pain, how can they expect their patients not to be!

In my opinion pain often doesn’t need to be reduced in those we see, and at times it doesn’t matter if it increases. I believe that if we as a profession are to play any role in trying to reduce this chronic pain epidemic that our society has got itself into due to its constant demand for quick fixes and avoidance of things that are difficult, hard, and uncomfortable, we need to start believing that getting people to do things that hurt isn’t bad. I do recognise this is challenging, alien, almost unthinkable for us as healthcare professionals due to our training, personal traits, and instincts as caring clinicians that tends to give us an inherent desire to help not hurt our patients. Some even think that its unethical and harmful to let pain countine or increase and that it breaks our first rule of healthcare…

but ‘do no harm’ doesn’t mean ‘do not hurt’.

So trying to convince physios and other healthcare professionals that it is OK to let pain exsist and not always try to reduce it and even try to increase it is hard. But its even harder to convince those who are experiencing it. Pain is an unpleasant sensation, it demands attention, it creates changes in behavior, and no one really wants it. But we need to start looking at pain differently. Pain is a fundamental part of our existence and without it we would be in a lot of trouble. Just think for a minute how it would be to live with NO pain. At first you may think it would be a gift to go through life living comfortably, easily, and you would be a super hero tolerating things others couldn’t.

Well its not like that at all. Living without pain is a curse not a gift. Those who suffer with the rare genetic condition called congenital insensitivity to pain go through life without feeling pain, but they cause themselves severe injuries and live in in constant fear and threat of having a serious illness going undetected until its too late. Just imagine what would happen if you didn’t get any pain when you bite your tongue whilst eating? You would most likely carry on chewing but now with a bit of extra tongue! What about when you lean on a hot cooker top, or cut yourself, or get an infection or some other disease and not know about it until you pass out or have some other symptom? Simply put, pain is a remarkable process that protects us and keeps us safe.

Not experiencing pain is not good, and in my opinion this is what’s happening to our society. We are not experiencing pain as much or as often as we used to. We reduce and avoid pain all the time with our easy lifestyles, modern technology, accessible medications, and constant molly coddling and over protecting. We have lowered our tolerance to pain and many now feel pain quicker, faster, and easier than before with lower and lower stimulus. The human race is becoming hypersensitive and intolerant to pain through its avoidance, and this is in part the fault of physios and all healthcare professionals .

What’s the solution?

If you’re intolerant to something the best way to become tolerant is through exposure, gradual, graded exposure. We know this works for load, allergies, phobias, even alcohol, and its no different for pain. In my opinion many who experience pain doing things that shouldn’t hurt such as bending over, getting out of chair, walking, lifting their arms above their head need exposure to these painful things to develop resistance to it, they don’t need further avoidance or pain reduction or even symptom modification.

I was taught as a physio to always try and reduce pain in my patients, and I used to try, but I wasnt always successful. Over the years I began to realise that it didnt matter if I did or didn’t reduce patients pain when I saw them. Patients who I didnt reduce pain seemed to get better, and patients who I did reduce pain didn’t always get better, in fact sometimes they got worse. It seems that many other factors decide if patients are going to improve or not other than creating changes in their pain when they come to see me.

I often find I am getting patients to do stuff that hurts and causing them some discomfort for a number of reasons. First is because those I see have been told to rest, reduce, remove, avoid the pain for many weeks and/or months and this hasn’t helped, in fact its made them worse. I often find myself having to be the mean bad guy telling patients to suck it up, crack on, and get going as no other bugger does. Doctors, therapists, family, friends often tell people in pain to NOT do things that hurt, and I understand this is good in certain situations, for a short periods, but not 3 months down the line for an episode of non specific low back, knee, shoulder pain.

Next getting patients to do things that hurt tends to be a shock for them and so confronts and violates expectations which can be hugely beneficial (ref). Many patients come to physio expecting a massage or something easy to do due to previous experiences or preconceptions, many don’t expect to be asked to something that hurts. Now don’t misunderstand or jump to conclusions about how I do this. I am not advocating a gung ho, macho, no pain no gain approach, screaming at my patients like some demented US Marine Drill Sargent. Getting my patients to do things they don’t want to do is not as aggressive or as hard nosed as you may think, but it is hard work, really hard work.

To get patients to agree to do things that hurt is difficult, most are reluctant and some flatly refuse. But with rationale compassion, robust encouragement, and confident reassurance most will do what I ask of them eventually. The key I find is to develop a good rapport with the patient early on, and this is easier said than done, but once established be persistent and confident as hell, and don’t promise things you cant, like it wont be as bad as you think, as it usually is, to begin with.

Another key point I find is to not let them do the painful task or exercise just once, but many, many times in succession. Eventually most realise that it wasn’t as bad as they expected and/or pain levels are reducing, this then starts to produce the confidence that they can expose themselves to more and more things that hurt on their own and they have control.

What tasks or exercises I get patients to do varies from patient to patient based on what they tell me they can not, or do not want to do. Sometimes its getting them to pick something off the floor, sometimes its getting them to reach up high, sometimes it involves me knocking them around a bit giving them some jolts, jabs, and sudden movements. My most special orthopaedic test in my physcial examinations is asking the patient to show me what they cant or dont want to do, and thats what I tend to eventually get them to do!

Another reason I get my patients doing things that hurt a bit is I like to give exercises and tasks with higher loads and dosages. Heavier, faster, more frequent exercises/tasks tend hurt more than lighter, slower, less frequent ones, but they do in my opinion create physiological and psychological changes sooner, faster, better.

What’s the evidence?

Despite common belief and assumption getting patients to do exercises and tasks that are painful doesn’t have many detrimental effects, in fact it may have a significant advantages over non painful exercises in the short term. A recent and important systematic review by Ben Smith and colleagues just published in the British Journal of Sports Medicine here has shown that exercises that cause pain up to around 5 out of 10 on the visual pain scale have no harmful or detrimental effects.

Source: BJSM, Smith et al (2017)

However, as with most things getting some people to do painful exercises or tasks is not a panacea or suitable for everyone, and so some caution is warranted in some populations. Repeated exposure to painful stimuli can be great in developing habituation to pain, but it can also create increased sensitisation to it (ref, ref, ref). It appears that some populations do not get the same top down inhibiting central responses with painful stimulus and so we do need to recognise this.

Also I dont think we always have to ask patients to do exercises or task that hurt. For example if there is a way to do the same task or exercise without pain then do it that way, you’d be fucking stupid not too. Sometimes creating a slight change in position, speed, load can reduce pain and if the task that couldn’t be done is now done, then job done!

So in summary the hypocrisy and contradiction of this profession fucks me off immensly, and those with personal agendas and vendettas will use offence as a thin disguise to shame others! They are just soft silly bi… billies. But many physios do need to stop being afraid of pain and stop being too soft on those they see with it. Asking patients not have those pain killers, that bit of tape, that massage, etc etc, and to carry on with tasks that hurt and even do things that increase pain is not harmful or bad. In fact it could be the best thing you do for them.

As always, thanks for reading

Much love

Peace out



12 thoughts on “Physios are too soft…

  1. Great post Adam! One of the joys I take in this line of work is getting called names (mostly out of love and affection) like “you’re a prick or an asshole” for getting people move or exercise into their pain. They usually follow up with “I forgave you after it felt better after the exercise”. While difficult like you said it is incredibly rewarding seeing that look in people’s eyes when you give them the power to help themselves and they know it! Keep up the amazing work you as…no that’s offensive…you fu…nope not that either…how about…nope someone will get mad at that…surely this word…nope nope social just warriors will be all over that one…have great weekend! Someone is probably going to take offense to that….fuck it! I’m going for a 🍺.

  2. Smashed it again Adam. Great blog and makes complete sense in modern day society where patients are becoming more and more sensitive to the littlest things in healthcare, especially musculoskeletal disorders.

  3. I think that you have made some really good points Adam. I think that your comment about not needing to avoid pain but also not needing to cause pain unnecessarily was important as well. I was taught that when treating patients to be as gentle as possible but as firm as necessary. I think that the second part gets lost on physios sometimes. I tell patients it doesn’t hurt to have good level of exertion discomfort. ;’ )

    One prof said tell your patients it will take you 10,000 reps of the exercise to recover. Crack on and do it regularly and as the reps add up your discomfort levels will continue to reduce. They will probably only do a portion of what you ask but the emphasis on getting on with it and doing enough to have a reasonable effect seems to stay with them.

  4. bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches bitches
    —> exposure

    How do you suggest we can differentiate between a person that will develop habituation to pain and one that will get sensitized? Dependant on acute vs chronic? Do you screen for this during history taking (yellow flags)? Or just go ahead and expose the patient and then evaluate their 24hour reaction after 1st treatment? …? Seems important to me for succes and compliance/commitment?

    Fantastic blogs btw! (and tweets πŸ˜‚πŸ˜‚)

    • I suggest looking and listening for then clues in the history of central sensitivity such as widespread distribution, hypersensitivity to other stimulus e.g. Noice, light, pressure etc, fear and kinesiophobia and also perhaps use the central sensitivity index PROM.

      But also do as you said check for 24 hour response! If pain is increasing and not settling after painful stimulus then I would say they are not going to respond well to painful tasks or exercises…

      Thanks for the comment… πŸ˜‚

      • Hi, sorry if I’m an idiot. Are you saying that those with central sensitivity are more likely to develop further sensitivity with exercises that hurt, or will they likely produce habituation. Or are you saying that they are the ones that you need to look more carefully into in the next 24 hours to decide if exercises into their pain is actually helpful or not.

        Also love your blog. Wish you did more shoulder courses in the Bay Area (USA)

        • Hi Kimura, yes those with higher levels of central sensitivity don’t tend to habituate to painful stimulus they tend to be further sensitised! However I would still try and see how much flare up and how long it lasts with everyone, but you may need to go slower with some than others!



  5. Great blog Adam. Hope to have contributed to that with our publications about #PEPT: Pain Exposure Physical Therapy in #CRPS

  6. Just one small item to change so that all the “facts” in your post are solid. My suggestion is “demented US Marine Drill Instructor.” It’s the Army that has a Drill Sergeant. There you go, now your post is up to Marine Corps standards. Keep up the great posts which help people like me overcome empathy burnout

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