The Big R’s… Reform or Revolution?

So the dust has begun to settle after the lastest Big R’s event held in Manchester this weekend and after a relaxing Sunday doing some gardening, going for a run, cooking a mean chilli, and now with a beer in hand, I thought I’d reflect on and summarise my thoughts and opinions on some of the main points. I also want to discuss what The Bigs Rs is again for those still confused or upset about it and talk a little about what I think the future may or may not be for this initiative.

This blog is a little longer than usual, but if you have ANY interest in the future of MSK physio within the UK and are in ANY way interested in how to improve it, grab a cuppa, beer, or whatever, take 10 minutes and read this through to the end to find out how you can be involved and contribute to future of MSK physio.

What is it?

The Big R’s is an initiative with a goal that’s very simple… to get the standard of musculoskeletal physiotherapy in the UK better. That’s it. Nothing more, nothing less!

Those attending and supporting The Big Rs events recognise that MSK physio in the UK has a problem… basically, a lot of it is crap and embarrassing, with many terrible patient encounters and poor experiences. Also, many recognise that MSK physiotherapy in the UK is not respected, trusted or valued by our healthcare colleagues or commisioning bodies, but those attending and supporting The Big Rs want this to change.

Those attending and supporting The Big Rs recognise that a lot of the UKs MSK physiotherapy departments are staffed with outdated, poorly informed or poorly motivated practitioners lazily, idly coasting along doing the bare minimum and sometimes even less, without any care, responsibility, accountability, or repercussions!


Those attending The Big Rs are frustrated by working alongside these individuals as well regularly seeing patients who have been given terrible advice and dubious ineffective treatments and desperately want this to change. However, most are not getting any support or encouragement from their peers, managers or professional organisations to do this.

This is what The Big Rs in for, this is what The Big Rs is about. The Big Rs is a group of like-minded, passionate, dedicated but frustrated physios getting together in a non-hierarchical democratic community-based fashion to try and work together to drive much-needed change and to be proud of a profession they work so hard in.

Those attending and supporting The Big Rs want to improve the standards of MSK physiotherapy in the UK without bias, vested interests, elitism, egotism or narcissism infecting it like other special interest groups, professional bodies, educational institutions, or organisations often have.

What it’s Not!

Despite the many opinions, comments and claims The Big Rs is not Jack Chews, Connect Healths, mine, or any other individuals personal promotion platform. Just because Jack Chew and Connect Health took action, got the ball rolling, and are facilitating this initiative doesn’t mean they are leaders of the revolution.

Also just because The Big Rs is mostly a social media initiative this doesn’t mean its only for physios who use social media. The Big Rs is for anyone who is interested in progressing and improving MSK physio in the UK. It just happens that most physios who are interested in staying up to date and in touch with progress and advances in their profession have realised that social media is an invaluable source and an important tool. The lazy, idol, apathetic dinosaurs have not and will not.


Those who continue to complain, whine, snipe and attack from sidelines with petty, pathetic negative comments about The Big Rs are either these lazy, idol, apathetic dinosaurs, or they are misinformed, threatened, or simply jealous of the attention it’s receiving.

Finally, Big Rs is not against or in competition with The CSP. Instead, it recognises that The CSP has done, and will continue to do, very little to address these issues due to historical traditions, lack of resources, or general apathy. If The CSP wishes to help and support The Big Rs then that’s great, if they don’t, then that great too.


So to the event in itself and some of the key points I got from two days spent in Manchester. The first thing to say is The Bigs Rs is not like any other physio or health care event I have been to, and this is a great thing. All too often at conventions, conferences, symposiums or whatever you call them attendees are passive recipients being talked AT by the speakers.

At The Bigs Rs the format was different in that the speakers talked WITH the audience. After a short presentation on their topic, the speaker handed over to two others speakers on a panel for some quick counter arguments and then the floor was opened to the audience to join in on the discussion.

Never have I been to a conference where so many audience members wanted to stand up in front of 150 other people and have their say. The passion, desire, eagerness, angst, and frustration was palpable in the room at each session. Unfortunately, this meant some questions were more speeches, and not everyone could be heard or have their say. However, an interactive question board that anyone could post their comments on to display in front of the group was a nice touch.


The themes of the discussions over the two days were around exercise, pain, the biopsychosocial approach, manual therapy, education, and research. All of the sessions I went to were great but I just want to discuss some of the best bits.

Physiotherapist or Registrar?

One of the best bits of The Big Rs for me were the discussions around exercise in physiotherapy because I’m biased. It was recognised by many at the event that most physios do a poor job of prescribing exercises to those with MSK issues for lots of reasons, fear of causing more pain, lack of education, poor understanding of the physiological principles etc etc.

However, a key point that emerged especially during the discussions on advanced practice was that exercise isn’t valued within our profession. For example, for a physio to progress their career in MSK they often have to abandon exercise. For a physio to become an Advanced, Extended Scope, or First Contact practitioner or whatever they are called these days they have to abandon their rehab and exercise skills and learn other medical skills such as injections, scanning, or prescribing.

I know this first hand working as an Extended Scope Practitioner myself 2 days a week. I have been trained and given responsibility to order and review scans, blood tests, to do injections and scans myself and even consent and list patients for surgery, but technically as an ‘extended scope physio’ I am not allowed or supposed to give patients any rehab or exercise advise when I see them.

This is just nuts and it is harming the physio profession and decimating physio departments across the country as skilled senior physios leave to ‘advance’ into more medical roles and departments. Where are the advanced exercise physios? Where are the band 8a physio rehab posts? Where are the rehab ‘consultant’ physios?

Simply put there are none. To get promoted as an MSK physiotherapist means either turning into a manager or an orthopaedic registrar. This needs to change!

Patient Stories, Manual Therapy and Harm?

Another key part of The Big Rs event for me was listening to some past patients explaining their journey and issues they had with physio and the healthcare system. As clinicians, we often moan and complain about poor practice that we come across, but to hear it from patients is something else. Hearing how it affected their lives, causing them more concerns, issues, treatments, and costs was sobering.


Whether you choose to believe it or not there is a lot of poor harmful physiotherapy practice out there. This is not me or others being negative, pessimistic, or overly critical, just honest and frustrated and this needs to change!

The harder question is what is poor or harmful physio and how do we police it? I tried to discuss this in my session on manual therapy but was only partially successful. The difficulty we have with poor harmful physiotherapy is it’s not easily noticeable or immediate in its negative effects and providing evidence of it is even harder.

Rarely do patients die or suffer from severe physical adverse reactions to some shitty advice, or crappy manual therapy, or pissy ineffective exercises. The most common harmful side effect is patients don’t get better or slowly deteriorate. The simplest way I try to highlight the harm that physiotherapy (and other MSK healthcare) is doing is to get physios to look at the prevalence rates of chronic pain.

Despite advances in healthcare and improvements in diagnosis and treatments, rates of MSK pain continue to rise at an alarming rate. Now I know this is due to lots of factors such as sedentary lifestyles, poor nutrition, lower education levels etc. But the poor advice, management, and ineffective treatments by physios and other healthcare professions is also to blame.

And yes I did have another go at manual therapy again at The Big Rs event because it needs it. Most of the poorest advice and most harmful explanations within physio I find comes from those that use and apply manual therapy. Manual therapy is still explained by most very poorly about what it is and what it does.

Manual therapy just isn’t some highly skilled specific treatment that takes weeks, months, years and £1000s of training to learn it. Manual therapy doesn’t have any specific effects, it doesn’t speed up healing or improve outcomes or results. And finally, manual therapy simply doesn’t need to be and should not be given by highly skilled well-trained physiotherapists at a premium price at taxpayers or insurance companies expense.

Manual therapy belongs in spas, salons, health clubs being administered by masseuses or technicians who administer it for its very short lasting and minimal relaxation and soothing effects.

The Other Good Bits

There were so many other good bits over the two days its hard to remember them all. However, the wonderful Jo Gibsons talk on the bastardisation of the biopsychosocial approach was a high, as was meeting Martin Ongwen a physio from Kenya and hearing his experiences from Africa and finding out his secret skill as a stand-up comedian and a sharp dresser.


It was also great to meet so many old faces from previous Big Rs events as well as meeting lots of new faces from all walks of physio, clinical, academic, and research alike. I think The Big Rs does a great job at simply getting likeminded physios together to share some solidarity and demonstrate that they are not alone in the wilderness of poor practice, apathy and idleness of day to day practice. This is cathartic and much needed for me and for many others I spoke to.

What Next?

A key part of The Big Rs is not to just talk but to also to plan and act. All the points raised in The Big R events so far are being collected, collated and organised and eventually placed into a Manifesto. You can learn more about this and contribute by joining The Big Rs community by registering an account here.

Joining The Big Rs community is also a chance for sharing best practice and highlighting the good that there is in MSK physio, because despite the poor, bad, and terrible MSK physio out there in the UK, there is also good, great, and brilliant MSK physio in the UK, I know I met most of them at The Big Rs.

What comes of The Big Rs is uncertain, it may change everything, it may change nothing, but I am willing to support it fully and give it ago because I’ve had enough of the poor, lazy, idol, ineffective crap and shit that infects my profession and I want to try and change it rather than just moaning about it.

I want to be proud to call myself a physio again, I want to show how physio can have a huge benefit for people in pain, with a disability, and in poor health. The critiques will say The Bigs Rs will do none of this, but at least it’s an effort and it’s more than most of these critiques are doing.

I’m willing to give it a try, are you?

As always thanks for reading


PS: A huge shout out to Jack Chew and all his team, Mark Reid, Jack March, Felicity Thow, Rich Barnes, and Charlotte Chew for their vision, insight, passion, hard work, and sheer bloody-mindedness to get The Big Rs off the ground and rolling.

6 thoughts on “The Big R’s… Reform or Revolution?

  1. Great reflective blog. You show in many ways how stagnant our profession has become. Looking forward to those advanced rehab roles being developed! I’m in 😉

  2. Being a dinosaur physio, it amazes me the amount of Millennial cynicism among pup physios.

    I think in trying to make physio application more science based, it would benefit from improving academic and clinical education of students….and filtering out naives.

    Many come into physio pwned by magical thinking that touch has some miracle healing power.
    Many think ailments can be exorcised via exercise, because well they are star athletes and they don’t have low back pain.

    These naives only grow in their delusions as a process line of emotionally frail patients elevate them to beta Goddess status.

    It is a mistake to polarise physio into exercise versus manual therapy.

    I had the displeasure of working with a younger locum physio in Australia recently who was as arrogant as he was tall, concrete, and pigeon holed in his clinical reasoning and application.
    To cut a long story short, the patient we shared benefited from massage and a brace, in addition to the very incomplete exercises prescribed by the Scottish Laird.

    I came into physio from a biological science background and immediately had issues with much of what I saw, especially electrotherapy. I see a similar thing happening more recently with the use of kinesio-tape.

    I’ve seen physio practise eroded as naive money driven narcissists over-serviced for 20+ years, losing the trust and business of exercise prescription to exercise physiologists. The response of the physio profession to this attack on their domain was zero. It was as if the profession knew it was guilty and had no answers to the problem of its celebrity authorities dishing out nothing-burger therapy.

    Those whose identity is firmly entrenched in the title physiotherapist are the biggest threat to the improvement of the profession. If physios want to be more rooted in science, then they have to humble themselves enough to accept where that science takes them.

    And what if that means 70% of what physios make a living from is better resolved with healthy diet, better sleep and stress mgt, and weight loss….without exercise or hands on therapy? Of the 300 odd physios I’ve met, about 3 could accept this.

    • Hi Bruce, it sounds like you should have been at The Big Rs… we do accept some dinosaurs… ;o)

      You make some very valid points and I agree with most of them, from naive millennial physios, lazy and workshy, to the dogmatic egotistical narcissists physios.

      I also agree that most of what we do is amuse patients whilst natural history does the rest, our job is to NOT make people worry more or worse with our silly over or under treatments, be that manual therapy and/or exercise based.

      I disagree that physio shouldn’t separate or move away from passive modalities including manual therapy mainly because of costs. NHS tax payers and insurance companies premiums should NOT be spent on people getting back or neck massages. There is no denying manual therapy helps some people, but they should get it from a service provider not a healthcare professional.

      I look forward to seeing you at the next Big Rs event Bruce if you can get your old creaking dinosaur bones moving ;o)



      • Your comment is bang on here. I cannot opine on the specifics of your overall piece out of lack of knowledge with anything but the Canadian system, but I am certain that no one has the cobblers to host such a shin-dig here for risk of upsetting the status quo.

  3. I really identify with your comment that physios have to abandon exercise and rehab toget promoted – I’ve seen it happen in the hospital I work in and the physio in question is now basically doing what a registrar would do; apparently when her supervisor asked her what her treatment plan would be he added the caveat “not physio”! It really annoys me but I didn’t realise that it had been more widely recognised, which gives me some hope things might change. Hanging on to my exercise rehab plans.

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