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The old, the new and the next in Physiotherapy

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Over the years I have followed different Physiotherapy “trends and fashions” (AKA modalities with a surname). Big business!! But all was with the good intention of becoming a better Physio. And just like modern celebrities, fashions come and go. New evidence contradicts old evidence and it becomes difficult to keep up, so we stay in whatever fashion we feel more comfortable within our line of work. Some fashions are more evidence-based, and other are more commercial-based. Fine. This article is not about judging. However, over the years (maybe even since the birth of Physiotherapy), there has been one modality (note I don’t call it fashion) that survives over time and evidence. It’s the One and Only, our corner-stone, the unbeatable and THE ONE … (don’t you hear the drums beating??) Yes, I’m referring to therapeutic exercise! Even the word Physio-Therapy refers to the therapeutic use of physical modalities. And you can’t get more physical than our body itself, right? Exactly, we ARE experts in the use of the body as a therapeutic tool. But somehow, we have taken our expertise for granted… maybe because EXERCISE doesn’t sell so well?? Or because WE don’t sell it so well??

In Spain, therapeutic exercise is an exclusive competence of Physiotherapists. However, there is a hypothetical possibility (by the time this article is being written), that this exclusivity is “taken” from us, just like in other countries. So what if this WAS to happen?  How could they very dare to take our Precious? Would or should we let that happen? Why? Maybe… because we would be too busy fighting and complaining, instead of having a united front selling how bloody GOOD we  ARE at prescribing exercise as treatment and how WELL it works for (I may add) ALL painful conditions and many other health-related problems.

So, if therapeutic exercise was not an exclusive Physiotherapy competence any more. Would we have any other EXCLUSIVE competence in the treatment and management of painful conditions? If therapeutic exercise was  taken away from us, what would we be left with that is purely OURS? Actually, what are the Physiotherapy competencies? In fact, what is the definition of Modern Physiotherapy?

As part of my curious and disrupting nature, I decided to tackle the elephant in the room and contacted national and international associations of massage, osteopathy, chiropractic and Physiotherapy, as well as, well known researchers, patient advocates and social media “pain celebrities”. Believe me when I say that there were a lot of emails sent and very few replies received, with or without an actual answer.

Some Professional Associations of Physiotherapy, as well as the International Association for the Study of Pain (IASP) have documentation available regarding competencies of Physiotherapists. Note these documents are freely available and can be a very useful resource! However, none of these documents actually mention specific modalities. The International Federation of Orthopaedic Manual Physical Therapists (IFOMPT) replied that all their members have to be Physiotherapists, as well as have completed education accredited by IFOMPT.

Then I crossed the line of fire and I entered in the non-Physio world. I wasn’t sure what I was going to find… And then, I got an immediate reply from Prof. Jan Hartvigsen from the University of Southern Denmark. If you don’t know who he is, I’d recommend you look him up (you can find him on twitter as @JanHartvigsen). He is a very well-known researcher and has published a lot of brilliant articles in the field of back pain, in the Lancet, among others.. And, he is a CHIROPRACTOR! He offered me to Skype on the same day. Ok… I was not expecting that. Only now was I considering the potential repercussions on my professional life from having this conversation (and writing the subsequent blog article). Prof. Hartvigsen offered an honest and eye-opener conversation.

Wise words from Prof. J. Hartvigsen (extracts from our conversation)

Chiropractic has its roots in the alternative medicine point of view but many chiropractors have moved on and are now practicing based on modern evidence. Unfortunately, some chiropractors and chiropractic schools internationally are still stuck in that old alternative medicine paradigm that is not very evidence-based. In Denmark, in the 90’s, it was decided to licence Chiropractors and make them part of the Danish National Health System. This license would give them both rights and responsibilities. In 1994, a chiropractic education was stablished and integrated into the medical education program here at the University of Southern Denmark. It consists of 5 years of university education, where during the first three years 85% is the same education as for medical students. The University of Southern Denmark at the same time initiated a large multidisciplinary research program with a broad MSK perspective, and this has allowed chiropractors in Denmark to make the transformation from being a pseudoscience profession (yes, he used this word!) in the old paradigm, to become a modern evidence-based and integrated profession. It has been a fantastic journey – a lot of work but also fun.

– Prof. J. Hartvigsen

The evidence base is the same for Medicine, Physiotherapy, Chiropractic and other healthcare professions. The common ground is overwhelming, and the evidence-based foundation is the same regardless of profession. Therefore, health professionals should work together to avoid fragmentation of patients’ care. Not working together, not only brings fragmentation, but also confusion, wasting of time and money, AND can harm patients. By working together, we HELP patients.

– Prof. J. Hartvigsen

A sign of a mature profession is that it can change with evidence. Dentists, for example, are not doing the same as 100 years ago and nobody is questioning their identity. They are still dentists that have adapted and modernised their profession following modern innovation and evidence. That is what professionals do. The opposite I would argue is unprofessional and irresponsible.

– Prof. J. Hartvigsen

The strengths of Danish Chiropractors are their solid education. That is very similar to that of medical doctors in the diagnostic area. And of course, a modern education in the clinical field that has a strong focus on clinical reasoning, patient information, exercise and of course manual therapy, which is what chiropractors traditionally did and most still do. Physiotherapists have many of the same competencies but at least in Denmark their education is shorter and take place outside of universities. Internationally this picture can be exactly opposite in some places, it is al dependent on history, historic decisions and local traditions. In the future we may see a closer integration of Physiotherapy, Chiropractic and medicine at least in this country. It is not inconceivable that a future health professional’s education reform will merge educations even more to reduce confusion and maximise knowledge in the musculoskeletal area. All for the benefit of patients and society. Time will tell, but I have lived long enough to not rule that out.

– Prof. J. Hartvigsen

Following this jaw-dropping conversation, I needed to dig further. I didn’t have the answers to my questions yet! I needed a heavy weight Physiotherapist with a strong views willing to speak to me. Luckily, I found what I was looking for: Morten Høgh. Morten is a Danish Pain Specialist Physiotherapist, he has a MSc in Pain from King’s College London (UK), owns 3 large Physiotherapy clinics and is HEAVILY involved in pain education at national and international level. He is also my colleague Fellow in CNAP. Find him as @mh_dk on twitter and here his great blog.

In conversation with Morten Høgh

Morten agreed with me that we (Physiotherapists) are professionally changing and using all sorts of fancy equipment and techniques. But that transition is making us lose our identity. However, we need to acknowledge that Physiotherapy is changing and evolving, therefore, the definition of Physiotherapy needs to be updated. In fact, in the recent 2018 Annual Meeting of the Danish Physiotherapy Association, this topic was discussed.

Morten emphasises that Physiotherapists are good communicators and that we have time (or need to have time) to communicate and get to know the person behind the pathology. This communication forms the base to develop a therapeutic alliance that will be the key to a successful treatment. This alliance is based on trust and confidence built over time.

However, Morten doesn’t feel there are (nor should be) specific or exclusive Physiotherapy competencies or techniques:

Upon establishing the therapeutic alliance, each Physiotherapist will use a variety of methods individualized to the needs of each patient, including techniques likely to have  “placebo effects”. I’m not afraid of the word “placebo”, but I don’t mean cheating or being unaware of what is being done. Placebo effects simply describe all the things that we cannot (or at least; tend not to) measure. As a consequence of having very little solid evidence regarding the mechanisms behind most of our interventions, we need to pay attention to the effect that our treatments have. This is why I think that (modern) physiotherapists are good at quantifying and measuring the effect of the treatment. And of course, clinical reasoning needs to be always behind our treatment choices (including the use of placebo). And let’s not forget how important touch is – not only from a historical perspective, but in clinical practice to this day; good manual handling skills are essential for good communication, I think.

– Morten Høgh

Whether you agree or not with Prof. Harrtvigsen’s and Morten Høgh’s words, what can we conclude? In my humble opinion, I think Physiotherapy needs to accept we are changing. We need to make NOISE and be LOUD because WE are an important part of a health care team. But in order to achieve this, we need a “system upgrade”, an EVOLUTION towards evidence, starting from the universities, just like chiropractors in Denmark, and following all the way to the top and bottom. We cannot be left behind with dated knowledge and myths as part of our daily routine. If we are using placebo effect, we need to acknowledge it and be honest with the patient. We ARE scientists after all (Physiotherapy is a Health science, let’s not forget this). Others are coming behind and are quickly catching up with what used to be “our territory”. Like we say in Spain: “Renovarse o morir” (renew or die).

Spanish version

Foto del autor

María Galve Villa

Maria Galve Villa is PhD at the Center for Neuroplasticity and Pain (CNAP), SMI®, Dept. of Health Science and Technology, Faculty of Medicine, Aalborg University (Denmark). Her research investigates the use of digital mapping technology, and explores novel pain metrics to track, qualify and quantify changes of pain over time. Her research aims to capture, describe and evaluate the clinical picture of painful conditions using modern and accessible technology (e-health). Ms. Galve Villa completed her Physiotherapy degree in her native Spain, followed by an MSc in Neuromusculoskeletal Physiotherapy in Ireland. She has an extensive background with more than 10 years’ experience in different clinical settings in Spain, Ireland and Denmark. She has developed a special interest in the management of persistent pain and Complex Regional Pain Syndrome (CRPS). In the future she hopes to continue developing and implementing e-health and other digital solutions to bridge the gap between researchers, the industry and the individual.