Is Physiotherapy a Science?

[Rigil Kent]

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:

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

[Peter Grant]

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.

[benguela]

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 . 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.



 

[GCoe]

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.

[Brian]

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.

[GCoe]

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.

[benguela]

@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.

[GCoe]

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"

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

[BlueRecurve]

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.