Physios identity crisis…

Is musculoskeletal physiotherapy going through an identity crisis? I don’t mean the kind that makes it dye its hair, wear leather trousers and tries to impress other professions half its age. Rather is musculoskeletal physiotherapy struggling to find its place and purpose in society and in an evolving health care service?

The musculoskeletal (MSK) physiotherapy profession has produced a huge amount of research recently in an attempt to demonstrate its worth and effectiveness. Unfortunately, a lot highlights that it has little to no significant effect above and beyond placebos, natural history, or regression to the mean, and people are beginning to notice (ref). Patients are beginning to realise that a lot of MSK physiotherapy doesn’t do much, and so are many physiotherapists and healthcare commissioners.

This has created a lot of debate and disagreement, with many advocates for certain interventions fighting hard for their cherished treatments, and others like myself questioning their worth. Some have talked about this crisis within physiotherapy with blogs telling us how ‘physio will eat itself’ and books called ‘The End of Physiotherapy’ both of which I urge you to read.

However, MSK physiotherapy continues to limp forward and struggle on, desperately searching for its place and purpose within health care, with the debates and arguments raging on about whats the best treatment for this pathology, or for that problem. But is MSK physiotherapy focusing its efforts and energy in the wrong place? Has it lost its way and in need of a drastic shift in its identity of what it is and does as a profession?

Treat or prevent?

The vast majority of MSK physiotherapy research and the physios themselves invest a lot of time, energy and effort into diagnosing and treating disease, disability, and illness. This is clearly important and should be continued, but what about the other side of the coin? What about our efforts in the prevention of disease, disability and illness.

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Do the profession and those who work within it invest as much time, energy, and efforts into the prevention of disease, disability and illness? Do the profession and its individuals place as much importance, credence, and relevance on the promotion of health and wellness as it does on the treatment of disease and illness?

Simply put… HELL NO!!!

Most, if not all of MSK physiotherapy’s training and practice is focused on the reduction of pain and the improvement of function in those with a disease or pathology. Very little, if any time, attention, or opportunity is given to physiotherapists to work on the prevention of disease and pathology in individuals before they come to see them.

Simply put MSK Physiotherapy is a reactive profession, not a proactive one!

Now, I am not trying to be hyper-critical or overly negative here, and yes I’m sure there are some physios who do work proactively in some health promotion roles, but they are in the minority, and they are not well seen or heard. This needs to change drastically.

Currently, MSK Physiotherapy, along with many other medical professions is bogged down in the endless ever-increasing pressures of treating pain, pathology, disease, disability, and illness to do much about the prevention or reduction of them. This is a classic vicious cycle if there ever was one, and it’s one that is leading us into a right royal shitstorm.

Tsunami of illness

With an ever-growing, ageing population, doing less and less physical activity, with poor lifestyle behaviours, declining health, and greater co-morbidities, our healthcare system is facing a tsunami of chronic illness and disability that is going to swamp the system and those who work in it.

For example, it is estimated that by 2050 the UKs population will have expanded by another 10 million people with a significant increase in those over the age of 60 (ref). It is estimated that this increasing elderly population will have far higher rates of chronic morbidities such as obesity, diabetes, and cardiovascular disease. In fact, it is estimated that in just 10 years half of the UKs population will be clinically obese and the associated health issues of this alone will cost the NHS a staggering £25 billion (ref).

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There is simply no way our healthcare system can cope with this, and if it only keeps focusing on treating rather than preventing disease it will soon find itself overrun will the chronically ill and disabled. Therefore, more time, effort, resources and opportunity needs to be placed as a priority into the prevention of disease and illness, and I think the MSK physiotherapy profession is in a prime position to help and respond here.

However, as I said earlier theMSK physiotherapy profession is very much focused on and set up for the diagnosis and treatment of disease and illness rather than the promotion of health and wellness. And if you don’t believe me just take a look at its training, its career structure, and its position within health care and society in general.

Physio training

Currently, most if not all undergrad and postgrad MSK physiotherapy training is focused on diagnosing and treating pain and pathology, very little is spent on health and wellness promotion and advocacy. This needs to change!

More emphasis, time, and energy are needed to train and enthuse physios on the importance of health promotion and advocacy in all those they see. They need more training and skills in how to develop and encourage behavioural change in people and how to overcome barriers and obstacles to healthy lifestyles, far more than they need training in what setting to use on an ultrasound machine or how to press a painful back.

Physio careers

Currently,  most if not all MSK physiotherapy career pathways are focused on and dedicated towards extended or advanced skills in diagnosis and treatment, there are virtually no career options for those physios who want to focus on health and wellness promotion. This needs to change!

For an MSK physiotherapist to progress their career they have to do further training and get certification in either manual therapy, acupuncture, dry needling, diagnostic imaging, injections, or even prescribing medications. For an MSK physio to be seen as advanced, enhanced, or specialised they have to twist, contort, and turn themselves into some bastardised version of a doctor, registrar, or radiologist. I know this because I am one.

And this is not to be disparaging, negative or critical of all the ESPs, APPs, or FCPs or whatever you want to call them out there, as there are some excellent ones doing some great work. But where are the Extended Scope Physios in health promotion? Where are the Advanced Physio Practitioners in exercise and activity prescription? Where are the First Contact Physios in schools educating children on the importance of healthy lifestyles?

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The MSK physiotherapy profession needs to take a long hard look at its career structure and stop placing emphasis and credence on skills that only diagnose or treat and start to place more on the skills that promote health. Simply put we need more young physios enthusiastic and striving to become health and wellness advocates, not junior doctors.

Physio in society

Currently, most if not all MSK physiotherapy is positioned in reactive roles, treating people with problems sent to them. It is also still very much seen as a junior, inferior, even subservient profession to other medical professions. This needs to change!

More MSK physiotherapy needs to position itself outside of hospitals and medical centres, and into gyms, health centres, and even schools. Health promotion and advocacy should begin from a young age and physiotherapy should be lobbying governments and pressuring policymakers about the benefits of placing physiotherapists and health and wellness teachers into the national curriculum.

MSK physiotherapy wants to try and position itself as being seen as a profession that helps promote health and wellness as much as it helps treat disease and illness. Our leaders and societies need to do more to push this forward using lobbying and other political pressure.

With the World Congress of Physiotherapy currently on in Geneva this weekend, it is encouraging to see the odd slide and comment about this already, but mpore needs to be done and I do wonder how much of this is talk and how much action will come of it?

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Summary

As I mentioned at the beginning, the MSK physiotherapy profession needs a drastic shift in its identity and thinking of what it does, and where its role and worth lies. Is it in the diagnosing and treatment of pain and pathology, which hasn’t been shown to be that great or effective, or is it more in the prevention and reduction of pain and pathology through the promotion and advocacy of health and wellness?

Obviously, the answer is both! But at the moment MSK physiotherapy is very much focused on the treating more than the preventing, it’s more reactive than proactive, and if it wants to survive and be taken seriously as a ‘health care’ profession this needs to change!

As always thank for reading

Adam

 

 

11 thoughts on “Physios identity crisis…

  1. Maybe health promotion in the field of mindfulness would be a good start. We’re still too wrapped up in assessing the body instead of the effect of training the brain in its relationship to the body

  2. Spot on, as usual, Adam: wellness and prevention should be the next BIG THING. Two comments: 1. In the US fee for service system, it is difficult to get paid for wellness and prevention sevices today, BUT 2. Employers are desperate to keep their aging skilled workforce working and employers know that they aren’t getting value out of today’s reactive healthcare.

    Thanks again for your thoughtful insights.

  3. You have made many points that are worth fleshing out further. Regardless, the profession of physiotherapy is much less a coherent organization of theory than it is a conglomeration of seperate interests barely held together. Case in point, the use of the descriptor, “MSK” to specify something in the physiotherapy profession is a huge reach. Perhaps if there was more unity in the profession, there would be less need to create false competencies in areas where there may be little to none. Physio wants claim expertise in some of these areas as if such reductive thinking will lead to success (and self-confidence), but this has never been demonstrated.

    There us no such thing as an “MSK physiotherapist”. That is a myth generated by an insecure profession struggling with its identity crisis, never resolved. Until physios stop needing to divide themselves professionally into divisions, little reformation is possible.

  4. I couldn’t agree more but as was pointed out in the post on your site about physiotherapists not having even the basic knowledge of the current minimum guidelines on exercise prescription how can we promote a prevention culture? We all know that the general public have a ‘fix me’ mentality and are unwilling to even consider investing in their own health and that unwillingness is seen within our own profession, unfit, overweight physiotherapists. Hardly a good example.

    Yes there are a few who do try and promote health, but do they have the resources to provide this? On the whole I’d say no. I treat (?) people with genetically inherited diseases that affect muscles and nerves but every patient who comes through the clinic is advised on exercise and health but can I use the hospital gym for a group session? No.

    Prevention is key but that requires a shift in the way physiotherapists are educated and position themselves in the health service but more importantly it requires a paradigm shift the general population attitude to taking responsibility for their own health. Sadly a big ask in todays society

  5. People come to a physiotherapist when they want to fix a problem.
    To prevent that problem in the first place, the proactive physiotherapist has to come before.
    And that could be done through educating people. Nowadays there is an abundance of media channels through which the education could be done efficiently.
    Yet, do the “doctors” have the time and the will to do that?
    I see the crisis. Leaving the white robe in the office could be a first step.

  6. Adam, your assessment hits the mark:

    “Currently, most if not all MSK physiotherapy career pathways are focused on and dedicated towards extended or advanced skills in diagnosis and treatment, there are virtually no career options for those physios who want to focus on health and wellness promotion. This needs to change!”

    “For an MSK physiotherapist to progress their career they have to do further training and get certification in either manual therapy, acupuncture, dry needling, diagnostic imaging, injections, or even prescribing medications. For an MSK physio to be seen as advanced, enhanced, or specialised they have to twist, contort, and turn themselves into some bastardised version of a doctor, registrar, or radiologist. I know this because I am one.”

    In Australia, the Australian Physiotherapy Association, representing 26,000 + therapists, is on the one hand pushing for training extended scope physiotherapists in disciplines such as rheumatology and pain management, whilst on the other hand it is endorsing courses in Dry Needling (focused upon the neurophysiology of pain and myofascial trigger points) as being suitable Professional Development Activities for its members.

    I agree that the promotion and advocacy roles you mention are important gaps to be filled, but I also see a danger that recommended training in pain management will be based upon the neurocentric dictum that “pain is an output of the brain.”

    The important existential dimensions of the experience of pain may not be included in such training and, as a result, physiotherapists will be nothing more than biomedical poor relations.

  7. Great read!
    Just two thoughts:
    1. If we get into gyms(as an example) are we not stepping on other professionals roles like Sports therapists? (A big role that they do see in uni is about health promotion…)
    2. Is it just msk PT or does medicine need a global shift to a different approach? (Rhetoric question as I do think this is the case). Have you seen Ian Harris’ talk ‘Surgery: the ultimate placebo?’? If not here is the link https://youtu.be/IzueFu1cq5U

  8. I love this blog- if physiotherapist health promotion roles existed in my area, I would be in one! I feel like I spend my time doing this anyway with the patients who present to my clinic, but if we could speak to people before the pathology develops, how much more impact could we have?
    Well said!

  9. Hi Adam

    Thanks for another thought-provoking post.

    I am in the final year of my physio studies, but have been fortunate enough to have positive influences who share your emphasis on a proactive approach to health.

    Cheers

  10. As a physiotherapist working in primary care I believe health promotion is one of the key directions that our profession needs to move towards. Especially with a decline in physical education in schools and rising obesity worldwide. I just gave a couple talks to diabetes and women’s health promotion groups about the role of lean muscle mass on not only movement but also glycemic control. It always amazes me how little the general public knows about the benefits and importance of exercise not only for participation in leisurely activity but prevention and management of chronic diseases.

    This is where we as physiotherapists can become champions of active healthy lifestyle changes and have a great impact on improving public health.

  11. Couldn’t agree more. I assessed an ESP a few weeks ago who had a lateral epicondylopathy that they were trying to self manage with self administered acupuncture. An ESP???! They wanted to see a colleague who properly acupuncture it! I was dying to puncture her bubble and tell her she was talking shit but but my lip and tried a gentle approach to nature of tendinopathy and the role of exs. The response was beautiful, “I’ve tried some exs from google but they didn’t help!”. This from an ESP! Thanks for adding the articles.

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