The Big R’s…

You may have seen on social media an event that was held this week called ‘Reasoning, Responsibility, and Reform in MSK practice’. This event was put together by Jack Chew and The Physio Matters Podcast team and Connect Health. I was fortunate enough to be invited to this and want to share my thoughts, feelings, and insights on it with you. If you want to check out more follow the hashtag #TheBigRs on Twitter.

Now my attention was piqued when the invite landed in my inbox that said we recognise there are many issues within MSK physio practice in the UK and solutions are far from simple, BUT we want to try and do something about it! The plan was to invite 60 clinicians, academics, researchers, managers, and policymakers up to Birmingham from various areas to meet, discuss, and potentially, possibly, hopefully, set some wheels in motion to move the profession forward, and so I thought why the hell not!

The first thing to say was kudos to Jack and his team for being able to bring together a group like this. Despite a few snide comments and jealous grumbles from some on social media that it was a selective, biased, elitist group of social media gurus, I will say that this couldn’t be further from the truth.

It was actually a diverse group of individuals from the NHS and private sectors, both clinicians, academics, and clinical academics alike. There were experienced frontline practitioners to young enthusiastic students and everything in between. There were also representatives from the special interest groups, the CSP, and NHS governance. I can assure you that this was NOT a homogeneous group who all thought the same, far from it, in fact, I think I have, had, and still, do disagree with over half of the people in that room.

The only commonality I saw in all the attendees was they all wanted progression and improvement for MSK physiotherapy, and that most were interested in staying current and informed and so most were on social media and twitter… as it is the BEST way to stay current and informed.

Change is hard

After some nibbles and coffee, the afternoon kicked off with Jack holding court for an hour trying to explain and justify why we were all here, he made some valid points about how we need to ask difficult and awkward questions and feel comfortable when others do this. He also made a good point about how we as a profession tend to lurch between luddites and mavericks, and that change is hard, really hard.


Next was a panel discussion with the leaders from Connect Health who put their points across about how MSK physio is evolving and what their ideas are on how this needs to be done. I found this session both interesting yet frustrating. It did at times feel like a recruitment and sales pitch for Connect Health, but I think this was unintentional, it was clear that these people were passionate about their business and the profession so good for them.

What I really enjoyed, however, was listening to Dr Graeme Wilkes who is Connects medical director, in fact, its fair to say I had a bit of man crush on Graeme by the end of the day. Graeme made a couple of key fundamental points that all physios need to take heed off and take action on fast.

The first is that physiotherapy has a great opportunity and is in a prime position to lead all MSK healthcare… but only if it acts fast and pulls its head out of it arse* (*my words not Graemes). The second point Graeme made superbly is that physios need to stop sucking up to orthopaedic surgeons and start to challenge them more and stop being subservient to them. I could have kissed him there and then!

I absolutely detest seeing and hearing physios fawning, following, and falling over surgeons at work, conferences, and online. Of course surgery has a role at times, of course surgeons are key members of a multi-disciplinary team, but so are we, and more importantly so are the patients.

We have lost our way!

Anyway putting my man-crush aside, I couldn’t agree more with Graeme even if I tried. The research and evidence around many orthopaedic surgical interventions for non-traumatic MSK conditions that scrape bits out, round bits off, tidy things up is extremely limited and being challenged and questioned like never before.

And the evidence for increasing physical activity and exercise in many MSK conditions has never been stronger or promoted more widely. Exercise is safer, costs less, and improves quality of life, and patient outcomes just as well, if not better than most orthopaedic surgery.

However, physios need to demonstrate that they are able and capable to deliver exercise-based interventions to patients without being distracted by the low-value passive modalities and fluff that constantly surrounds them. Simply put we need to get more physios to abandon many things and reduce the wide variation in how they practice across the UK, getting them to focus more on the core treatments of activity and exercise.


This is something that sounds simple and easy to do but actually is far from it. For example, I have been trying to promote a more simple active approach to physio for years, but have come up against barrier after barrier, mainly from those with personal, professional, and financial vested interests in the passive modalities. I have also come across many physios who simply lack motivation, enthusiasm, or are too lazy to abandon the things they have been using comfortably for years as there is no incentive to do this…

Let me assure you that it is no easy task to get physios and patients confident and comfortable with only advice, education, and exercise.

Traffic Lights

To try and help with this issue Connect Health shared their traffic light system they use to help their physios focus on what should, could, and doesn’t need to be done with patients. A GREEN LIGHT means there is strong evidence that this intervention SHOULD always be done. An AMBER LIGHT means ambiguous evidence so this intervention COULD occasionally be done. And a RED LIGHT means this intervention has no strong evidence of effectiveness and so DOESN’T need to be done. If a physio uses an amber intervention they have to justify why, and if caught using a red intervention they are reprimanded.

I think this is a great system and one that can be used widely. Graeme used the example of Therapeutic Ultrasound and how they have red lighted it and now removed it as an intervention for all MSK conditions. This was music to my ears and is something I hope could be carried forward from this meeting. I know it sounds like a small step but after speaking to Paul Allen from the Extended Scope Practitioners Network I think this could be one thing that can be realistically actioned across the profession to demonstrate some positive steps to come from #TheBigRs.

Some universities no longer teach therapeutic ultrasound to undergrads, and many departments have already decommissioned their machines, so if we could set up systems and procedures that ensures we look to remove all therapeutic ultrasound treatment in all MSK physio I think that would be a great success.


So I am going to start on Monday morning by yet again asking the management at both my NHS and Spire MSK departments that I work with to remove ALL the ultrasound machines. I expect some resistance and some ifs and buts as before, but I am determined to stand my ground better this time.

Group Discussions

The final part of #TheBigRs was the bit I enjoyed the most, the group discussions, and I wish we had longer for this and thought we could have done without the talks at the start being so long. Anyway, each table of 10 delegates had the task to discuss and debate around different topics and collate these into some key points to take forward. The topics were based on sector clashes, research accessibility and integration, professional boundaries, clinical governance, first contact roles, and the public perception of physio.

I was sat at the table discussing the barriers and opportunities of research accessibility and integration. The table consisted of Ben Smith, Brad Neal, Paul Kirwan all PhD candidates and clinicians, which you could easily tell as they all had rather attractive knitwear on! There was also Annina Schmidt a full-time PhD at Oxford, Seth O’Neil via Skype a recent PhD and clinician, Ash Shattock a clinician and head of the AOCP interest group, Matt Lowe a Spinal ESP and deep thinker, and Tom Jesson from Chews Health taking notes.


The discussions were fast and free-flowing, with Matt constantly using his fancy big words, however, the first thing we all agreed on was research is fundamentally important and we need to be better at engaging, reading, and implementing it. The barriers are still the usual culprits of time, access, apathy and boredom. So the key question we had was how do we get more physios aware, engaged, motivated, and interested in the research and evidence base.

A suggestion we came up with was to try and get more physio departments to fund and appoint physio research champions or specialists. These posts would be split between clinical and research time with their primary role to keep the others members in their department up to date with current research and findings.

The next point we came up with is to get the undergrad physio programs focusing more on the importance of the evidence base from day one of a physios education. We all agreed that the emphasis on reading, analysing, and critically reviewing research is not there at the beginning in many universities. However, if an undergrad physio is educated and enthralled right from the start of their education that research is a key area then hopefully this will stick with them for their career. We also touched on the usual ways to disseminate research findings better other than just dry boring research articles, things such as blogs, videos, infographics, social media etc.


Despite some uncertainties and resignations I had about attending this meeting I found it an interesting and worthwhile experience. It felt good to be in a room with other not so like-minded people who all had the same ambition to move the profession forward, however, I think the next steps of this venture are key.

It will be interesting to see if anything actionable or concrete comes from this over time even if it is something as small as getting a consensus, agreement, or even a decree about STOPPING all therapeutic ultrasound treatment in all MSK physio, which actually isn’t a small task at all, but one I will take as a step in the right direction.

I think all of the ‘Physio Matters’ team and those at ‘Connect Health’ should be congratulated for having the mindset, gumption, and enthusiasm to try to and put some action where their mouths are, and come Monday morning I am going to try to do the same… care to join me… NO MORE THERAPEUTIC ULTRASOUND IN PHYSIO.

As always thanks for reading


14 thoughts on “The Big R’s…

  1. Nice blog to better understand the purpose of this session for those of us that werent there and good to see some productive discussion.




  2. Hello, It was very interesting to read about your initiative to remove the ultrasound machines from your health care system and to move forward to more exercise based approach. You give the world a good example. I would like to see that happening in Bulgaria too. I am curious about the names of the universities that DOES NOT teach ultrasound to their students and when did that started at first place? Can you provide some refferences? Thank you Adam.

  3. Reblogged this on Physio Research to Practice and commented:
    I am not sure if this “Reblog” function is new as I am fairly new to all this. Anyways thought I’ll try this and see how it is like. It was excellent recap by Adam on The Big Rs event held last week. Again kudos to Jack Chew and team and Connect Health in organising this event and really being at the front lines in progressing the physio profession. And it was great to get a glimpse into what the event was all about by reading Adam’s blog.

  4. Hello Adam,

    I suspect your blog is a fair reflection of the RRRs meeting. I also suspect it will have rubbed some people up the wrong way; as you say, most probably due over inflated egos taking a hit. There may be a lot of physiotherapists who will judge this as a kangaroo court with the same old names ‘spouting off’ and a private company getting in on the act for commercial opportunity. Whilst this type of event can never be free of bias, someone has to start the ball rolling; personally, I feel it is something that should have been driven by the CSP about fifteen years ago.
    The ultrasound issue in itself will be enough provocation for some. Like most passive modalities, it is probably very difficult to justify from any facet of evidence base, especially its actual contribution in patient management. In private practice I think there are major issues with such practice. I don’t think physiotherapists are willing to let go of passive treatment of any kind due to the competition using it. There also appears to be the added issue of being regulated by a government body whilst others are allowed to seemingly make any statement they wish without any come back; perhaps as physiotherapists we should shout more about the fact we are regulated in this way.
    Personally, I have experience of trying to practice in a evidenced way, using advice, education, exercise based rehab and treating people with decency; it has lead to a significant drop in income and difficult to make up by turnover in an area that has its socio-economic problems.
    The other elephant in the room is education in physiotherapy. When we have evidence that yellow, blue and black flags, self-efficacy,locus of control and health literacy are significant factors in patient outcomes yet still seem to be largely ignored, the situation is bizarre. When there is evidence that addressing psychosocial issues along with exercise based rehab and promoting self-efficacy can give optimal outcomes it is difficult to comprehend the passive treatment culture.
    Slightly off piste, I sometimes wonder about physiotherapy prescribing in the light of the effectiveness of certain drugs.
    It sometimes feels like the Inverse Teaching Rule 1 is prevalent; the chances of a subject being taught or advocated is inversely proportional to its importance.

    Keep up the essential work,
    Kind regards

    • I have had the same experience in my private clinic – evidence based physio is not attractive- after the first assessment and advice regarding exercises I usually give pt an option to give me a call if they need me. They very rarely do. I am not sure if they go to other clinics to get some MT or just following my advise and getting better.

  5. No more ultrasound! Perhaps the new rallying cry for physios (or physical therapists here in the states). It seems that there are numerous ways that we can move our profession forward in similar fashion, but as you note, it will take a lot of effort as so many are entrenched in the way it has always been done. Worse still, with our private system of healthcare here in the states, using many of those amber and red light procedures makes for a much better income. Maybe with the time saved in not teaching some of these techniques, more time could be spent in ethics, as really, isn’t it simply the ethical thing to stay current and offer the best possible care? Anyway, thanks for writing, and we’ll keep reading.

  6. Thank you Adam!!
    As you mentioned educational programs should be very careful with offering “historical intervention” methods within their curricula. Perhaps within the perspective of previous used methods to show the direction we move in to.

  7. Sounds a great session. I really like the idea of traffic lights to guide and prioritise evidence based practice, but the definition of a red light you described could be questioned I think. Shouldn’t a red light be the use of an intervention where there is strong evidence that outcomes are unfavourable as compared to other treatments (e.g. injection for tennis elbow). Being reprimanded for trying interventions with no strong evidence would stifle innovation surely? How would we ever progress clinical practice if we get excessively dogmatic? It’s a great concept but needs some thought as to how it is implemented with specific patient populations.Well done to the organisers.

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