Here’s a question; is musculoskeletal physiotherapy going through an identity crisis? I don’t mean the kind that makes it start dying its hair, wearing leather trousers, and trying to impress other professions half its age. Rather is musculoskeletal physiotherapy struggling to find its place and purpose in an evolving health care system as it continues to search for evidence of its effectiveness in treating pain and pathology?
Over the past few decades, the musculoskeletal (MSK) physiotherapy profession has produced a huge amount of research in an attempt to demonstrate its worth and effectiveness. Unfortunately, a lot of this research highlights that MSK physiotherapy has little to no significant effect above and beyond placebos, natural history, or regression to the mean, and people are beginning to notice. Not only are patients realising that a lot of MSK physiotherapy doesn’t do much, but so are many health care commissioners, and physiotherapists themselves.
This crisis causes a lot of debate and disagreement, with many advocates for certain physiotherapy interventions fighting hard for their cherished treatments, and others like myself questioning their worth. Some have talked about this crisis within physiotherapy before with blogs telling us how ‘physio will eat itself’ and books called ‘The End of Physiotherapy’ both of which I urge you to read.
Yet, MSK physiotherapy continues to limp forward and struggle on, desperately searching for its purpose and place within health care, with the debates and arguments raging on about whats the best treatment for this pathology, or for that problem. However, I think MSK physiotherapy and those of us who work within it are focusing our efforts and energy in the wrong place. I think MSK physiotherapy has lost its way and needs a drastic and monumental shift in its identity of what it 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.
Does the profession and those who work within it invest as much time, energy, and efforts into the prevention of disease, disability and illness? Does 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 entirely focused on the reduction of pain and the improvement of function in those with a disease or pathology. Very little, if any time, or attention, or opportunity is given to physiotherapists to work on the prevention of disease and pathology in individuals before they come to see them.
MSK Physiotherapy is a reactive profession, not a proactive one!
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 and 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).
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.
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.
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?
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?
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