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Is Physiotherapy a Science?

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GCoe
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« on: April 27, 2010, 11:23:08 AM »

Hi

I am a physiotherapist. In response to benguela in a post a good while back it is a constant source of professional embarrassment that so many physiotherapists deny good science in their practice. The uncritical adoption woo and pseudoscience within the profession is rife although I don't think you would find that physios are worse at this then Nurses, GPS or many other mainstream health practitioners.

However  the basis for all branches physiotherapy is applied science where we rely on evidence. Our background science is the biomedical sciences, particularly anatomy, physiology, pathology and biomechanics. We draw heavily on the applied exercise sciences and movement science. Physiotherapists in most western countries are instilled in evidence-based practice. We now can rely heavily on clinical guidelines and systematic reviews that are in turn based an excess of 3,000 randomised controlled trials to base our practice on. We have one of the most comprehensive databases for evidence-based practice that is devoted solely to physiotherapy (PEDro)

One reason why a number of physiotherapists adopt kooky ideas in their practice is that physical medicine is by its nature dramatic and very prone to placebo effects. When you are working within the realm of touching people which is a big part of physiotherapy practice the non-specific and placebo effects are often ramped up - much more so than prescribing a pill for instance. It isn't just the patient that gets fooled - therapists that fail to keep a skeptical viewpoint of their practice, get sucked into thinking they are being more effective then they really are and draw wrong conclusions about cause-effect relationships. We and are often influenced by charismatic practitioners who run short continuing education courses who provide "certainty of effectiveness" if you just follow their methods (this is where a lot of dubious practices such as acupuncture are adopted).

Some countries do better at producing and maintaining science-based physiotherapy through high quality faculties and high professional standards. Countries such as Australia, Canada and the better courses in the US are good examples. So there is a marked difference between nations.

Physiotherapy is a valuable part of health science but we have our problems. We could do better.

I'd be interested to know what members have found in their dealings with physios
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GCG
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« Reply #1 on: April 28, 2010, 10:29:45 AM »

i had to attend physio three odd years ago when a 500kg piece of concrete fell on my back.
a tiny woman, highly pregnant, but by god, did she have a squirming in agony.
but she fixed me up real good.

in my mind, physiotherpy as definately a science.  you have an injured muscle, or muscles in spasm, you apply pressure or heat or friction, and it affects the muscle fibres to relax, release, whatever.  no hocus pocus to that.
i dabble in massage therapy as well, and i have felt, with my own hands, a knotted muscle release after work being done on it. 
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benguela
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« Reply #2 on: April 28, 2010, 14:40:02 PM »

Hi GCoe,

I would like something to the equivalent of FishMS. We'll call it QuackMS Wink

Whenever a physio,gp,etc is about to perform or prescribes a treatment, I can send an sms to QuackMS of the treatment's name and it replies with one of the following

 "proven to work for x,y,z",
 "possibly works for a,b,c the jury is still out",
 "does not work, name and shame the quack"

In my case I injured my spine while canoeing, a nerve was pinched in my spine causing severe pain in my ass. I forget the exact name of the nerve, not the one that runs down the leg, everybody mentions that one, just in the ass. Everytime I moved it was like an electric shock from my spine to my ass. I am a sportsman and have always used physiotherapy. For this the physio gave me the works, laser, electro, thermo, acupunture, dry-needling, massage etc. Not coincidently they were the same treatments when I was recovering from acl surgery, when I stretched the ligaments in my ankle and when I cracked my hand. It's like a shotgun approach, use all the tools and hopefully one works, doesn't matter what the injury is, it's all just muscles, ligaments and bones.

Yes, eventually the pain went away. The orthopedic surgeon said I wasted my money, it would have healed itself anyway. That pissed me off and left me wondering if anything he had used had actually shortened the recovery period, or was I ripped off? I speculate that somethings work and some don't, but which one. Please just use the ones the work so that it doesn't cost an arm and a leg.

For example, what I have found so far in PEDro is that studies show dry-needling to not be more effective than placebo and "possibly works" while others studies come out and say it does not work period. To me "possibly works" equates to "does not work", I don't understand why they cop out like that on PEDro but I'll allow that option in the QuackMS responses.


and @gothcatgirl, your evidence is anecdotal, which proves nothing.







 













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GCG
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« Reply #3 on: April 28, 2010, 14:54:47 PM »

an·ec·dot·al  (nk-dtl)
adj.
1. also an·ec·dot·ic (-dtk) or an·ec·dot·i·cal (--kl) Of, characterized by, or full of anecdotes.
2. Based on casual observations or indications rather than rigorous or scientific analysis: "

indeed not.
you say youre a sportsperson.
my ex is an extreme athlete.  runs, bikes, paddles, climbs.  has torn ligaments, cracked bones, collided with cars, drowned, you name it.

he was born with a misaligned spine.  so when he does adventure racing, he often returns with his back in agony.  with a nerve pinched somewhere.  cant sit, cant lie down, cant stand.
i have no training in any form of medicine, real or woo-woo.  i use what is commonly called common sense.
a muscle is made out of fibrous collections of cells.
the reason the nerve is pinched, is cause a musle is in spams, causing the nerve to be deprived of oxygen, contorted, overexposed to stimulus,  and a whole bunch of other stuff.

why does the muscle do this.  the cells are oversaturated with waste by-products of being overworked, either by repetition or unusual strain. or simply damaged.
thus, eliminate the lactic acids and what the hell ever is else is present, and your cells with chill out.
how do you do this?
you encourage bloodcirculation to said area.  by applying pressure, heat, any and all stimulation.  i use massage, with alternating hot and cold packs.  and some deep heat.  if that actually does anything apart from smelling shitty, i dont know.

so the blood brings more oxygen to the area, helping the healing of torn and overworked muscle,  clearing out waste.
basic biology.
rigorous or scientific analysis, proven plenty times over.  by scientists, not woo-woos.

for needling, acupuncture, meridians and whatnot.  i havent had experience to any of it, so i cant comment.

so anecdotal fail.
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benguela
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« Reply #4 on: April 28, 2010, 15:42:49 PM »

@gothcatgirl

Your theory on how massage therapy works does not prove it's correct, I'm not saying it's incorrect, what I'm saying is that it's just speculation. Your comment

Quote
i dabble in massage therapy as well, and i have felt, with my own hands, a knotted muscle release after work being done on it.


is anecdotal, or at least my understanding of anecdotal, I may be wrong here.

This is the kind of evidence that is not anecdotal or speculative

http://search.pedro.org.au/pedro/browserecord.php?record_id=1219

I must thank you for leading me to this information on sports massage, from now on I will only pay for a massage at my next race if I'm suffering from cramps and I need to finish before the cutoff. Definitely not because I need to recover in the evening for the next day's stage. I'm embarrassed of all the money I spent on those masseurs up to now!

And let's talk about common sense, common sense told me that quantum theory is bs, and yet, it's true, it's both a particle and a wave!





« Last Edit: April 28, 2010, 16:08:59 PM by benguela » Logged
benguela
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« Reply #5 on: April 28, 2010, 16:33:00 PM »

why does the muscle do this.  the cells are oversaturated with waste by-products of being overworked, either by repetition or unusual strain. or simply damaged.
thus, eliminate the lactic acids and what the hell ever is else is present, and your cells with chill out.


and as it turns out your theory may be pooched

Does Massage Therapy Work?

physiotherapy, it's conspiracy! Wink


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GCG
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« Reply #6 on: April 29, 2010, 10:10:46 AM »

Limitations of massage   
    * benefits are modest
    * benefits are temporary
    * benefits are inconsistent

I am no athlete, so it was curious for me to see how well trained muscles work, as opposed to my couch potato variety.
Obviously, each person's body reacts differently to each stimuli.  My ex would go for a 10km run, and hardly break a sweat, i would be dying 2kms in.
he never has stiffness from training, i have barely anything else.
my point is, my 'theory', as you prefer to call it, is no theory at all.  its basic, entry level, high school biology.  a cell metabolises sugars delivered via the bloodstream, its breaks it down, in the process oxygen is used, and by-products are expelled.  this is a hugely simplistic view, and im not going to go into the details, unless you really want to get technical.
there is nothing woo-woo about cellular workings.

alltho, scientists and doctors are not super convinced that lactic acid causes Delayed onset muscle soreness (stiffness), they cant say its not this or that.
at best, i would say, its a number of factors, such as muscle fibres being torn at cellulat level, saturation in chemicals not conducive to optimum cellular working, and stuff i surely have no clue about.

the point is, the 'theory' you are referring to, is proven fact.  and if you searched hard enough to disprove this, you will find solid evidence to counter the earth being round as well.

massage therapy, depends greatly on your understanding of mammal metabolism.  if a qualified medical practitioner had to attend to me, i would assume he understood what entails doing things in the correct manner.  as opposed to a myriad of blonde bokkies at every beauty parlour, selling their massage therapies.  if you have a genuine injury, see a genuine doctor.
for some injuries, i do confess, they can poke and prod you till rapture comes, and you will still heal only as fast as yoru body allows.  the point of massage, especially in the back, is to help the muscle relax,  not heal it.  why?  cause your back is a complex array of support musles for you spine. if one is not working as it should, the other overcompensate, and often you end up with pain all over the show. 
and as for saying tht despite the ministrations of therapists or not, you still heal in time.  sure.  that's a given.  as much as a broken leg will, too, heal in time without any intervention, but it with qualified attentions, it will be good as new, in a faster manner.  as opposed to half-baked and crooked.

i wont dwell on this any longer, as i see no need to hash this out any longer.

as for your take on quantam theory.....erm, what?
i doubt highly you understand the intricacies of that science, and neither do i, and sure as hell dont have the energy to go research it at length.  so enough of that.
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benguela
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« Reply #7 on: April 29, 2010, 13:42:06 PM »

and if you searched hard enough to disprove this, you will find solid evidence to counter the earth being round as well.

What is your criteria to decide that a piece of "solid evidence" falls into the "the earth is flat" type of evidence?

The evidence I presented is

"Massage Impairs Post Exercise Muscle Blood Flow and "Lactic Acid" Removal"  from the Journal of Medicine & Science in Sports & Exercise published 2009

and the other is

"Effectiveness of sports massage for recovery of skeletal muscle from strenuous exercise" from the Clinical Journal of Sports Medicine published 2008

Are these journals and/or authors disreputable?


















 

 




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StevoMuso
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« Reply #8 on: April 30, 2010, 00:56:12 AM »

I have disc prolapse. When my back plays up I go to see a physio who specialized in backs in the USA. She twists my body around until the slipped disc is in a certain position and then manipulates it into place. It's brilliant and definitely puts the disc back. I stagger into her rooms almost on all-fours, and walk out upright and completely free of pain. The muscle cramping that accompanies the slipped disc also gets fixed quicker with manipulation by the same specialist.

I don't think physio is just an expensive back-rub - in my case it has been a proper scientific medical procedure, so it may not be correct to generalize.
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« Reply #9 on: April 30, 2010, 08:46:22 AM »

I know squat-all about physiotherapy, but what I do know is that my b/f studied it for two years before taking a left turn into a different field, and when I drag myself home with an upcoming migraine (I get them often), he does this "thing" with his hands pushing certain pressure points on my scalp, and my god, it recedes within a half hour. Whether that has any scientific backing or its just the fact that I'm getting loving attention and touch from someone who cares about me, I dont know and also dont care. It works, and that makes me happy.
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GCG
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« Reply #10 on: April 30, 2010, 15:58:13 PM »

i think, its really cool and normal to be skeptic about stuff,  and since that is what we do here, kinda expected.  but to be skeptic about EVERYTHING, is a bit much.
so chill out bra.  if you think you are so hardcore that you dont need a therapist to get your broken body back on track, go for it.  in my experience, athletes are, in general, quite narcissistic, and you believe yourself to be right. all. the. time. 
that's why my ex is still without a medical aid.  or a decent job. or a house. or a car....... coz he's right, and everybody else is wrong.  but go run it off, while i chomp down on a chocolate while playing medal of honour on my ps2.
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benguela
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« Reply #11 on: April 30, 2010, 19:34:21 PM »

As GCoe has pointed out, there is a lot of woo in physiotherapy and not just the usual suspects like acupuncture, even some of thee "mainstream" treatments are on a very flaky foundation. That is not to say that it's all flim-flam. But just because they are currently perceived to be on the "allopathic" side of the fence does not make it right for them to throw in some woo, and charge for it. What they are doing could even be life-threatening and should be considered malpractice.

In much the same way that a GP who dispenses allopathic medicine should not be dispensing homeopathic remedies, a physiotherapist should not be providing therapy that is not evidence based.

I know I probably won't convince you guys no matter how much evidence I present, but I hope to sow the seeds of doubt that may, in-time, germinate. Who knows, there could be a libel case one day in the future like Simon Singh's case against the chiropractors.














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cyghost
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« Reply #12 on: April 30, 2010, 21:21:57 PM »

I know I probably won't convince you guys no matter how much evidence I present
That is simply bullshit. If you provide the evidence, people here will look at it and critically examine it. If it holds up to scrutiny, it will be accepted. That is the skeptic way.
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benguela
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« Reply #13 on: May 01, 2010, 08:52:59 AM »

If you provide the evidence, people here will look at it and critically examine it. If it holds up to scrutiny, it will be accepted. That is the skeptic way.


I completely agree, I have produced the evidence, please look at it and reply. Would you say the evidence is poor or flawed? Have the replies so far from the skeptics been exemplary? They have seemed to dismiss it.
The arguments so far are accounts of their personal experience, second hand experiences of their boyfriends, some speculative hypotheses and the stunningly conclusive,"you can't be skeptical of everything"! Is that the best this forum has to offer?

When I read things like this

"Until further evidence is available, current practice and widely published rehabilitation protocols cannot either be supported or refuted." this is from Rehabilitation for hamstring injuries (Cochrane Database of Systematic Reviews 2007;Issue 1)

then I conclude that some of the treatments that physios do is ethically wrong and should at this stage not be called science. We have to be skeptical of what they are doing and take them to task.










« Last Edit: May 01, 2010, 11:20:54 AM by benguela » Logged
Peter Grant
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« Reply #14 on: May 01, 2010, 11:05:29 AM »

I'd like physiotherapy to become a bit more standardised. Some physiotherapists swear by manipulation whist others judge the practise too dangerous as the risk of injury to the spine is too high. Some consensus in the field would be nice.
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Rigil Kent
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« Reply #15 on: May 01, 2010, 11:27:31 AM »

Benguela, if we squarely disregard anecdotal accounts as evidence for the effectiveness of physiotherapy, then I forsee a grave problem in evaluating its effectiveness at all. And that includes evidence like:
Quote
The orthopedic surgeon said I wasted my money, it would have healed itself anyway.


To evaluate, we must measure. So, first of all, how do you propose we measure the effectiveness of physiotherapy, if not subjectively?

Stevemuso's slipped disc is easy - its either in place or it ain't. But how about muscular pain relief? How do you measure that, if not by verbal account?

Mintaka
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« Reply #16 on: May 01, 2010, 11:51:25 AM »

To evaluate, we must measure. So, first of all, how do you propose we measure the effectiveness of physiotherapy, if not subjectively?

Stevemuso's slipped disc is easy - its either in place or it ain't. But how about muscular pain relief? How do you measure that, if not by verbal account?

Mintaka


Whether or not a treatment provides pain relief is somewhat subjective, but whether or not the associated risks are acceptable to the profession should not be. I click my own back and it does provide pain relief, but the long term effects probably aren't good.
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benguela
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« Reply #17 on: May 01, 2010, 12:05:24 PM »

So, first of all, how do you propose we measure the effectiveness of physiotherapy, if not subjectively?
But how about muscular pain relief? How do you measure that, if not by verbal account?

Very good questions, thanks Mintaka. Your questions have led me to investigate this and I learnt that in medicine a case study is anecdotal evidence based on a large sample of anecdotes, the study is then peer reviewed. Case studies are not the best form of evidence but it's the best science can do in many cases Wink. Therefor I retract my first statement and now assert that the anecdotal evidence I presented is better than  the anecdotal evidence presented on this topic from individual skeptics. It would require a larger sample of anecdotes, from skeptics, to be considered as evidence.



 



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GCoe
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« Reply #18 on: July 01, 2010, 12:24:15 PM »

Sorry for not replying for a while. I lost this site for a bit

I agree that it would be good to physiotherapy become more standardised. One would hope that you should receive the best possible treatment based on the best possible evidence. Physiotherapy is moving in this direction although unfortunately not all in unison and not all at the rate as many of us would like.

It should be pointed out that physiotherapy is a very broad discipline and the aches and pains, musculoskeletal injury type of physiotherapy is just one branch of practice. For example I practice in neurological physiotherapy so that is more helping people with problems such as stroke, MS or Parkinson's Disease with movement and function. another very important branch is cardiopulmonary physiotherapy and there are many smaller specialities such as those working in womens health, occupational rehabilitation and prevention and so on.So it gets quite hard to draw generalisations.

However when consulting a physio here are some suggestions:

While there are lots of specific evidence based treatments, on the whole active exercise and guiding people towards the resumption or increase in physical activity are strategies that have been found to be effective in a very wide variety of conditions and injuries. In contrast more passive modalities such as electrotherapy, applications of head and cold, massage, manual therapy often turn out to be disappointing. Please note these are generalisations and the inclusion of passive modalities as part of a treatment plan may have their place some of the time. However they have been greatly overrated and overused. A therapist that concentrates heavily on passive modalities is probably not going to deliver the goods. One reason why these passive modalities have been heavily relied on is that they do make great placebos!

Ask the therapist to provide evidence for the treatment they are recommending. The therapist should be able to provide you with well conducted systematic reviews of clinical trials or at least some well conducted clinical trials of their treatment to justify their treatment. This is not always the case, particularity in less common injuries or conditions so to be fair the physiotherapist can't always oblige. However this is a good practice for patients to ask: it drives therapists to be more accountable in their practice. If the therapist scoffs at doing this by denigrating evidence-based practice, resorts to anecdotes or to fanciful theories then shop elsewhere.

If you want to check out the best evidence for a particular treatment for a particular problem there are a number of resources but one of the best is PEDro's patient-friendly database:

http://search.pedro.org.au/physiotherapy_choices/findrecords.php?-type=new_search

PEDro is the Physiotherapy-specific evidence-based database. It is limited to research-based treatments but is quite extensive.

Therapists should be aware not just of a specific problem such as pain, weakness  or stiffness, but should be able to relate this to your daily activity, how the problem is affecting the participation in life areas that matter to you and how the problem is affecting the quality of your life. Treatment goals should take into account these broader issues. In the end physiotherapy is about helping you get more out of life.
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« Reply #19 on: July 01, 2010, 16:44:08 PM »

again speaking as a patient I've had several serious procedures including fusing three vertebrae in my neck (totally painless), a total knee replacement TKR(frecking painful) etc and each time Physio was required. The TKR took 8 months to reach approximately the same degree of flex in my knee as a normal knee and without physio would never have happened. It was painful but critical. A science...no I believe that's an incorrect question...each patient is different and while the science lies in understanding the human body, the treatment (whether it be systematicly, correctly or idiosyncraticly indicated) may differ. Is Physio useful? Yes in most instances it is but it also has its limitations.
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GCoe
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« Reply #20 on: July 03, 2010, 04:25:19 AM »

Physiotherapy is and should be essentially an applied science. Of course the patient must be treated individually and there will always be and art aspect to practice. However utilising science-based data provides so many benefits to patients over therapists who base their practice solely on clinical experience (basically anecdote), their pet theories, and what they were taught on continuing education courses or in their undergraduate education of many years gone by. The scientific literature provides evidence for most aspects of physiotherapy whether it is diagnosis, prognosis, effects of specific interventions, risk of harm, systematic evaluation of patient experiences etc.

Physiotherapists who fail to utilise evidence in their practice in a meaningful way are letting both the public and their profession down.
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« Reply #21 on: July 05, 2010, 13:09:26 PM »

@GCoe

I have been to a physio for the following 3 sports injuries

1: ACL replacement surgery from bad skydiving landing.
2: Pinched nerve in lower back from impacting with a rock in a rapid while kayaking (or falling out of kayak in this case)
3: Stretched ankle ligaments from trail running.

The physio used the following treatment protocol for all 3 injuries

1: Apply heat to warm up the injured area prior to treatments.
2: Laser Therapy
3: Ultrasound
4: Electro Therapy
5: Manual Manipulation / Massage
6: Attempted acupuncture which I politely declined. I should have challenged the physio right there!

I was also given mobility/stretching/core stability exercises and later weights to do at home.

For all injuries the same treatments were used which appeared to be a shotgun approach. I'm guessing that if a sales rep sold the physio another gadget, it would be included in the standard treatment lineup that could be charged for.

After the acupuncture incidents and the opinion of a skeptical orthopedic surgeon, I started investigating these therapies on Pedro and discovered that the treatments are mostly bogus, including what i recently found out on this forum, the massage! What is in vogue lately is some patch that they stick on your body somewhere that apparently promotes healing or some such. I forget what it's called.

Would you say this lineup of treatments is typical of what one could expect from physio's in this country?

My conclusion is that physiotherapy needs to get it's house in order and expose these treatments as sham. The main problem I have is that they are perceived to be legit unlike homeopaths and chiropractors.













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« Reply #22 on: February 04, 2012, 02:52:30 AM »

It is a bit hard to generalise across your three conditions but my guess is you bought a dud. Looking through your list there - core stability exercises is a popularised term for an evidence-based treatment for certain types of low back pain. So in the context of low back pain this may be relevant to you - but it depends on your presentation - if you have functional instability between intervertebral segments in the low back that may be contributing to the "pinched nerve"

Quote
1: Apply heat to warm up the injured area prior to treatments.
2: Laser Therapy
3: Ultrasound
4: Electro Therapy

these are genially found to be useless treatments. although heat and certain forms of electrotherapy do have temporary pain relieving effects.

Manipulation may have a place in the treatment of acute low back pain but there again the effect is short lived and doesn't appear to alter long term recovery. Accupuncture MAY have some some benefits in reducing pain at certain sites but the result is most definitely due to the physiological sticking needles into people and not due to some pseudoscientific of energy meridians. However the effect size is small so if it really makes for clinical significance in the treatment is open too debate.

Physiotherapy has a definite role in rehabilitation of ACL surgery, and sprain ankles - without going into the specific treatments in detail, the therapy should focus exercise that improves the appropriate healing of ligaments such as graduated increases in normal stressing of the healing tissues (e.g. graded increase in stretching and load bearing of the affected tissues, to promote a stronger and more resilient ligament) , exercise to strengthen  the appropriate muscles, restoration of proprioception usually using some progressive balancing exercises, and the therapist should address other issues such as keeping you fit (aerobic exercise such as cycle ergometry, or arm ergometry, treadmill as tolerated etc.). If you are involved in a manual occupation or specific sport the programme should design include task-specific exercise that will get you back to such activities safely and as quickly as possible.

Physiotherapy in South Africa is quite advanced relation to academic activity with a good research profile. However I couldn't comment on the practice in private practice. Unfortunately just having good university training and research profiles doesn't amount to best practice in the field.

I agree that physiotherapy needs to get its act in order and there is much to do. However I would maintain that physiotherapy continues to have a legitimacy over such things as homeopathy and chiropractic - physiotherapy is very much a branch of allied health science and is part of medical science where as homeopathy and chiropractic are not. In the case of physiotherapy it is a matter of quality of practice that needs improving and that improvement needs to come from translating high quality clinical research into practice
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« Reply #23 on: October 24, 2012, 17:59:24 PM »

Having been treated for various injuriesand strains by both physiotherapists and chiropractors (and seeing the effects of such treatments on numerous family members and friends) I do think there is a science to the disciplines. Saying it's not a science would be like saying medicine is not a science. A lot of studies go into these disciplenes, sciences revolving around the fuctioning of the body.

Admitedly, chiropracty curing infant cholic is bull (and it's claims like these that make people think chiropracty is airy fairy nonsense). But chiropracty helping realign the skeleton, does actually work.

@Benguela. The actupuncture needles are not used in the way Chinese medicine does. The needles are inserted into deep areas where the physio cannot reach to help blood flow reach that particular area. It has worked on me and my family. Was there placebo involved? Maybe? But then I think placebo has a huge effect in any field of medicine.
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