How physiotherapy and healthcare is changing – new evidence and best practice

Healthcare is always changing and evolving, as new technology, refined techniques and current research dictate best practice. It can be difficult for both clinicians and patients to accept certain new ways of thinking, with many beliefs strongly ingrained in our minds and often out-dated practices still considered the norm. Consider that not long ago the belief was commonly held that eggs were bad for your heart health or that cracking your knuckles would cause arthritis. These have been proven to be myths. Remember when we used to treat infections by attaching leeches to the skin? Probably not, because as more refined techniques emerge we replace the older, less effective (or sometimes outright wrong) ones.  

Evidence-based

Physiotherapy is an evidence based profession. While not all circumstances will fit a clear-cut, textbook approach to treatment, it is important to have strong justification for the decisions we make. As best as possible, this should be backed up by research which has shown some level of effectiveness. At the very least, we should certainly be avoiding anything that has been proven to potentially be harmful.

Less imaging and diagnosis

Imaging techniques, such as x-ray, MRI and ultrasound have long been a staple of our diagnostic repertoire. Not sure what the issue is? Go get a scan. Unfortunately, it’s not always so simple and sometimes this course of action can have negative health outcomes.

Firstly, we need to unpack why it is we are sending people off for imaging. The simple answer would be to get a clearer diagnosis, right? However, consider these interesting facts. One study showed that:

• 80% of people over the age of 50 years old show signs of disc degeneration
• 60% of people over the age of 50 have bulging discs.

Even if we look at the over 20 population, those numbers are still 37% and 30% respectively. If we look at 80 year olds, the numbers are a staggering 96% and 84%!

Almost makes you think that these are somewhat “normal” signs of ageing, right? With that in mind, would an image of a 50 year old patient’s back really help you pinpoint what is the problem causing their pain? Considering that most people in that age group will show physical changes such as those described above, it doesn’t seem very helpful. If you are 80 years old, having signs of disc degeneration is almost as likely as having 10 toes on your feet. So what is it really telling us?

Now this is not to undermine the use of this brilliant diagnostic technology. There are a plethora of reasons why we would definitely want imaging done, but in the chronic pain population, there is certainly a trend of over-imaging. This can inherently lead to worse outcomes, because patients who are not equipped with the information outlined above, will go home thinking “my back is ruined, I will never get better” and evidence has shown that these negative beliefs about our pain lead to prolonged suffering. A big part of chronic pain is psychosocial – meaning that how we perceive our problems can dictate how likely we are to overcome them.

In terms of diagnosis, naturally we want to find a culprit. We want to be able to point to a structure and say “it’s my inflamed tendon” or “it’s because I have weak glutes” or “the physio said it’s my L4/5 disc”. Unfortunately it isn’t this simple. Firstly, if we consider what we now know about imaging (that is, most people’s scans will show some sort of “abnormality”) then we can’t always say what is the cause of somebody’s pain with complete certainty. Sure, their scan may have showed a bulging disc, but so do many other people’s, some of whom don’t suffer from back pain. When we step into the chronic pain realm, the factors which affect our experience are complex. This is why we need to move beyond a short-sighted structure-based approach, and start looking more broadly at the individual’s overall movement patterns, lifestyle, expectations, beliefs and goals.  

So how does this translate into physiotherapy practice?

The basics of treatment are simple, in that we need to promote movement and get people to feel empowered about their own health and treatment goals. When an individual feels that they are powerless and only a therapist can “save” them, then their outlook immediately becomes less promising. It is imperative that as part of any treatment regime, educating the patient is emphasised. This way the patient understands how their treatment plan is being formulated and can have a say in the decision-making process. We need to focus less on diagnosis and finding what is wrong with the person, focusing more on people’s strengths and what they are capable of doing. Scaring people with words such as “degeneration” does not serve any helpful purpose. Instead, it is vital to get the message across that our bodies undergo many normal changes as we age. Sometimes these can lead to dysfunction, but not always. Additionally, most of these problems can be overcome with the right plan in place. Results won’t always come immediately, but a concerted effort where the therapist and patient have a healthy communication channel is key.