MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

“Physiotherapy generally offers a highly science based approach to clinical practice.” This was a recent comment by someone (I presume a physiotherapist) on this blog. It got me thinking – is it true or false? I am in no position to review the entire field of physiotherapy in a blog post. What I will do instead, is list a few alternative therapies often used by physiotherapists.

  1. Acupuncture: many physiotherapists seem to love acupuncture. In the UK, for example, they have their own organisations. The AACP is the largest professional body for acupuncture in the UK with a membership of around 6000 chartered physiotherapists, practising medical acupuncture. They state that there is an increasing number of research publications in the UK and worldwide proving the treatment effectiveness of acupuncture when compared to (chemical) medication for example.
  2. Applied kinesiology: some physiotherapists offer applied kinesiology. This clinic, for instance, states that applied Kinesiology combines a system of muscle tests with acupuncture, reflex points emotion and nutrition to find any imbalances present in the whole person.
  3. Bowen technique: many physiotherapists use the Bowen technique. This practice advertises it as follows. If you’re looking for a way to treat tightness in your upper back, neck or shoulders or are suffering from respiratory pain or headaches, The Bowen Technique could be the answer you’re searching for. Achieving all these things as well as being a great way to treat sports injuries and enhance sporting performance, this therapy also promotes emotional wellbeing. A non-invasive therapy, it is equally suited for the treatment of acute (short-term) and chronic (long-term) conditions.
  4. Craniosacral therapy: some physios also employ craniosacral therapy. Here is an example. Craniosacral therapy as experienced by thousands of babies and people all around the country, has a proven track record at easing and relieving what makes babies upset. If your baby suffers from:
    • Colic
    • Wind
    • Digestive issues
    • Reflux
    • Unsettledness
    • Sleep problems
    • Ongoing crying
    • Difficulty with breast feeding/latch/suck
    • Other problems

    then call…

  5. Cupping: One physio writes this about cupping. It was good to see the public (Western cultures) exposed more to cupping therapy practice thanks to the recent Olympics in Rio 2016. Last Olympics in London 2012,  the Chinese and Japanese Athletes, amongst neighbouring nations, were readily seen to use and advocate the practice, along with the approval no doubt of their large team of Medical and Physiotherapy related support staff. This time however it has bridged to divide to Western World Athletes, such as Michael Phelps (he of 23 Olympic Golds fame). This advocacy of the practice and again the presumed support from his Medical and Sports science entourage with team USA, is a good barometer of the progress and acceptance within Western Medicine, for Cupping Therapy.
  6. Massage therapy: in many countries, massage and related techniques therapy always have been an integral part of physiotherapy.
  7. Feldenkrais method: The same applies to The Feldenkrais Method® is based on principles of physics, biomechanics, neuroscience, and the study of human motor development. Feldenkrais recognized the capability of the human brain to learn and relearn at any age – neuroplasticity. The method utilizes slow, gentle movements, and awareness of subtle differences to optimize learning, improve movement, and make changes in the brain.
  8. Kinesiology tape: If you have suffered an injury or illness that causes a problem with your functional mobility or normal activity, you may benefit from the skilled services of a physical therapist to help you return to your previous level of mobility.  Your physical therapist may use various exercises and modalities to help treat your specific problem.
  9. Reflexology: Here is what the UK Chartered Society of Physiotherapists writes about reflexology: Developed centuries ago in countries such as China, Egypt and India, reflexology is often referred to as a ‘gentle’ and ‘holistic’ therapy that benefits both mind and body. It centres on the feet because these are said by practitioners to be a mirror, or topographical map, for the rest of the body. Manipulation of certain pressure, or reflex, points is claimed to have an effect on corresponding zones in the body. The impact, say reflexologists, extends throughout – to bones, muscles, organs, glands, circulatory and neural pathways. The head and hands can also be massaged in some cases. The treatment is perhaps best known for use in connection with relaxation and relief from stress, anxiety, pain, sleep disorders, headaches, migraine, menstrual and digestive problems. But advocates say it can be used to great effect far more widely, often in conjunction with other treatments…
  10. Spinal manipulation: Physiotherapists learn spinal manipulation as part of continuing education courses in Canada. The Orthopaedic Division of the Canadian Physiotherapy Association is responsible for the standards of education and supervises exams required to meet the standards of the International Federation of Manipulative Physiotherapists (IFOMPT). In many other countries, the situation is similar.

These 10 therapies have all been discussed on this blog before. They lack

  • plausibility or
  • proof of efficacy or
  • proof of safety or
  • all of the above

In other words, they are NOT highly science-based.

QED

62 Responses to “Physiotherapy generally offers a highly science based approach to clinical practice.” WISHFUL THINKING OR TRUTH?

  • You published the following about Feldenkrais already may be it needs to be discussed further on? It looks like this method could be integrated into clinical routine? But I think they have a lack of profound medical knowledge because they do not even learn neither anatomy nor pathology in their trainings and their “graduation” is a “yodeling degree” because nearly everybody passes it successfully … may be it’s better done if physical therapists apply it and not free floating practitioners?
    https://edzardernst.com/2015/06/an-alternative-treatment-that-could-actually-be-integrated-into-clinical-routine/

  • I share the concern expressed above that the science base for physiotherapy is thin at best, the profession attracts many practitioners who lack a critical approach to camistry (CAMs), some practitioners actively practice alternative techniques which have no plausible, reproducible evidence base (they are not alone, there are some doctors in this category) and that by deliberately conflating the undoubted benefits of much physical therapy practice with other modalities mentioned, such physiotherapists undermine the integrity of the profession.

    And yet…

    In my experience, most physiotherapists do appreciate the scientific method, apply it as best they can, do have high ethical standards, are critical and do move on from modalities which are shown to be ineffective.

    I only hope the profession of physiotherapy will continue to base itself in evidence and express wider critisicm of those of its members climbing aboard the quackery bandwaggon.
    Doctors need professional colleagues they can trust. More to the point, so do patients.

    • The science base for Physiotherapy is not “thin at best”. If you go to the Physiotherapy Evidence Database (pedro.org.au) you will find over 32,000 RCTs evaluating Physiotherapy treatments.

      • ok, then name a few (5 or 6) interventions/indications that are solidly based on evidence.

        • Graded exercise
          CBT
          Motivational interviewing (MI)
          Education (weak evidence and a bit vague I know – and possibly just a part of MI and CBT within PT scope of practice)
          OTC NSAIDs
          Rapid referral for red flag or otherwise concerning physical or mental health symptom patterns

          That’s 6ish.

          • Re: Gibley Gibley

            You assert that my list is not physiotherapy. Sorry dude,you’re wrong.

            Well, that is what contemporary physiotherapy looks like. There are few interventions that are specifically medical or physiotherapy. There are simply interventions that work or don’t work and are within the legal scope of practice for a specific discipline within a specific country.

            If a practitioner is providing interventions within this scope then they are providing evidence based care. (eg physiotherapy, GP, chiropractic, osteopathy)

            If someone is doing much beyond this list then they are playing in the land of woo.

            Disciplinary boundaries are more to with historical power plays than any reflection of specific competencies on the part of the practitioners of that discipline. (eg dubious universities assigning the title of Doctor to chiropractors, and PhDs to graduates of online correspondence based on “previous life experience).

        • If you want rigorous evaluation go to PEDro and search for Cochrane reviews of physiotherapy treatments such as the ones below. Of course not all physiotherapy treatments are effective (just like any area of health care). That is the point of PEDro; to help people choose what to offer to patients.

          Supervised exercise therapy versus home-based exercise therapy versus walking advice for intermittent claudication

          Yoga for improving health-related quality of life, mental health and cancer-related symptoms in women diagnosed with breast cancer

          • https://blogs.bmj.com/bmjebmspotlight/2018/09/16/cochrane-a-sinking-ship/

            So who do we trust????

            Graded exercise NOT EVIDIDNCE BASED
            CBT NOT PHYSIOTHERAPY SHAKE BAKE OR FAKE
            Motivational interviewing (MI) NOT PHYSIOTHERAPY
            Education (weak evidence and a bit vague I know – and possibly just a part of MI and CBT within PT scope of practice) ANYONE CAN DO THIS
            OTC NSAIDs REALM OF PHARMACISTS AND SUPERMARKET CHECKOUT S.
            Rapid referral for red flag or otherwise concerning physical or mental health symptom patterns YES

        • And why does the criticism of physiotherapy made by Richard Rawlins, an orthopaedic surgeon, escape unchallenged? The science base for surgery is thin, for orthopaedic surgery it is wafer thin.

          It is hard to take you seriously Edzard.

          • and what has that to do with me?

          • @Chris Maher

            You are parrotting a tired old trope that only proves you know practically nothing about surgery, orthopaedic or otherwise. Scientific approach to surgery is seldom possible using placebo controlled, blinded studies but there are other ways and means of scientific progress. Even in orthopaedics.
            I fear you will not understand it but let me give you a small parable that describes how science is widely used in surgery. Think of parachutes. they used to be crude and ineffective, today they are well developed wonders.
            No one wants to try parachutes in a blind study against placebo, right? That would be unethical and plain stupid. But you can develop and test variations if you go about it the right way and do the tests properly and with safety first. That is how we make progress in surgery even if it is difficult sometimes.

          • Björn…. an interesting recent review on the topic.

            There is currently insufficient evidence to support the specific efficacy of invasive procedures for the treatment of chronic pain. Very few studies have been done on any one condition, treatments and pain measures differed, and outcomes were inconsistent between studies. Quantitative pooling of outcomes for seven studies on low back pain and three on knee osteoarthritis showed no difference in pain at six months compared with sham procedures. At least for back pain and knee pain, sham surgical procedures explain the majority of the benefit, with confidence in these estimates being strong.

            https://academic.oup.com/painmedicine/advance-article/doi/10.1093/pm/pny154/5094687

          • What are you trying to say DC? This paper is neither interesting nor does it have any useful relevance to the subject.

            There are other experts here that are much more familiar with reviews and meta-analyses. But I can see several potentially destructive problems with this. It mixes together trials on extremely differing subjects, mostly small, mean N=80
            The problem areas are ridiculously heterogeneous:

            low back (N = 7 trials), arthritis (4), angina (4), abdominal pain (3), endometriosis (3), biliary colic (2), and migraine

            The procedures studied were even more vaguely defined:

            Invasive procedures were defined as when an instrument was inserted into the body (either endoscopically or percutaneously) for the purposes of manipulating tissue or changing anatomy.

            This included anything from plain old surgery, via partial meniscectomy to percutaneous lumbar facet denervation. And many more as can be seen e.g. in table 2A.
            And they look only at sham control if I got that right.

            This Potpourri they happily boil down to one (1) general conclusion. One wonders what the authors were thinking and why on earth this was published. Perhaps to stir controversy?

            We already know that controlled evidence is scarce in many fields and we already know that some procedures like partial meniscectomy are already considered or proven worthless. Such procedures are generally eliminated from health care in most properly governed countries even if some go more slow than others because, among other reasons, in some countries you can continue to sell whatever that fills your pocket even if it demonstrably does not work.
            This paper is not helping this process in any way other than perhaps demonstrate the need for proper audit and analyses.

            Let me try to put this way.
            This attempt at scientific hand-waving can be compared to taking a handfull of whatever lies on the ground in front of you and cooking soup on it. Even if there were some nice legumes or fruit in the mixture, their taste is spoiled by the weed and dirt, or is spoilt in the mix of unrelated ingredients. You need to pick your legumes, wash, define and sort them. Then you can make soup on each type separately or related species and see if they are worth the effort of soup making.

          • @Björn Geir
            “You are parroting a tired old trope that only proves you know practically nothing about surgery, orthopaedic or otherwise. Scientific approach to surgery is seldom possible using placebo controlled, blinded studies but there are other ways and means of scientific progress. Even in orthopaedics.”
            https://twitter.com/insightsbs/status/996284044953423872?lang=en
            BTW Ian Harris and Rachelle Buckbinder in this video clip have co-authored articles with Chris Maher.
            https://www.georgeinstitute.org/news/professor-chris-maher-named-one-of-worlds-top-two-back-pain-researchers
            If you are going to attack one of the top back pain researchers in the world I recommend you do your homework first.

          • @ Bjorn

            Also a tweet by Chris Maher about your reply above:

            Chris Maher
            Chris Maher
            @CGMMaher
            ·
            23h
            The blog from @EdzardErnst is the gift that keeps giving. Today an orthopod runs the tired old parachute analogy to explain why placebo controlled surgical trials are not possible. Oblivious to trials that do exist including the CSAW trial in @TheLancet this year.

            Interested to hear your reply to this tweet.

  • Having lived in Australia, UK, France and the US – I see a lot of overlap between different skillsets and much confusion because the professional nomenclature varies so much.

    In Australia, physiotherapists (and allied exercise physiologists) generally have a degree run in conjunction with a reputable medical school. However like pharmacists selling homeopathic treatments and candling services, individuals may choose to incorporate weird complementary practices into their treatments.

    • Hi Mike,
      It’s Accredited Exercise Physiologist and, in the main, we stick to exercise as a treatment modality.

      • Simon, Exercises have a limited effect in the treatment of Low Back Pain according to the Lancet. Especially in the acute stage.
        https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30489-6/fulltext?code=lancet-site

        Why do you use a form of treatment that has been proven to be ineffective, i.e. Exercises?
        In fact the shake, bake and fake of physiotherapy is based around unproven and ineffective forms of care. e.g. TENS, Shortwave diathermy, ultrasound.

        • I am calling out your post as misleading as I was an author on the Lancet paper you cite to support your post.

          This blog would be far better if people read research papers closely, cited them accurately and left the politics to the side.

          There seems to be some agenda here; but it does not seem to be the advancement of science.

          • and your comment would be far better if you had abstained from insinuation and extrapolation!

          • There is BS in physio like chiro.
            There are also superb researchers and reformers like Chris Maher, Paul Hodges, Lorimer Moseley, Mark Hancock (All Australian), Jan Hartvigsen, Bruce Walker, Christine Goetz, David Cassidy, Scott Haldeman, Greg Kawchuk, Simon French, Alice Kongstead, Iben Axen etc etc etc.
            Carpet bombing the physio’s like you do the chiro’s does not advance science FOR EITHER PROFESSION.
            So let me say it yet again:
            Step 1: Point out the BS.
            Step 2: Support reform, the reformers, research and the researchers.
            If you only do step one then you are the CARPET BOMBING critics.

            “This blog would be far better if people read research papers closely, cited them accurately and left the politics to the side.
            There seems to be some agenda here; but it does not seem to be the advancement of science.”

            Didn’t take Chris Maher long to figure things out.

        • GibleyGibley. Funny name! Why the anonymity? Do you like to pick fights a lot on these sites? My post merely pointed out the correct nomenclature for AEP’s and commented on their scope of practice. I didn’t discuss the tx of lbp, acute or otherwise.

          • Simon, you wrote……”Hi Mike,
            It’s Accredited Exercise Physiologist and, in the main, we stick to exercise as a treatment modality.”

            I asked you why do you use a form of care, “exercise”, that has been proven to be ineffective?
            I am not picking a fight, I am asking you to justify your rationale for treatment.

            Anonymity because I, like many other people on this post prefer it. e.g. D.C., Blue Wode and the “Franks”

          • OK, GibleyGibley it is. I don’t need to justify exercise as a treatment for lbp because, at no stage, did I state that exercise is an effective treatment for lbp! You left this out of my response to your previous comment: “I didn’t discuss the tx of lbp, acute or otherwise.”

  • Since “treating away pain” is a delusion not a scientific endeavor it is and will continue to be fueled by wishful thinking and throwing shit against the wall to see what sticks.
    If, as the authors of Biomechanics of back pain seem to show there are NO valid or reliable tests available to definitively diagnose “sprain/strains”, “trigger points”, “tight muscles”, “subluxation”, “facet syndrome” and only modest diagnostic prevalence in disc and SI joint involvement….all the ruminating, prevaricating and pretending to “really” know something about the internal workings of the body and it’s generation of pain is just a way of stealing money from the gullible and distressed. Resentful demoralization can be avoided and rudimentary “physiotherapy” should ideally be dispensed by MDs and their RNs in a medical setting whose methods are (generally speaking) within the purview of scientific-oversight. “Independent” practitioners whether DC or PT or Lac will always be prone to the greatest degrees of corruption and conniving. For these practitioners it is always about getting new victims and stringing them along indefinitely.

    • Hi Michael,

      Are you still a physiotherapist?

      Are you for or against physiotherapy?

      • Crickets.

        • @cc: you have iterated the same piffle for what seems years. Why haven’t YOU “reformed” YOUR profession? Could it be it can’t be?? The 8% of the populous that is ensnared seem to embrace the subluxation-dogma and it appears the most successful clinics are those pandering to them. “Reform”, if inclusive of the elimination of subluxation-dogma would spell disaster. The capacious number of PTs, fitness clubs and massage therapists is ample to make DCs doing their “reformed” bullshit superfluous.
          So do you want “us” non-believers, those who know Chiropractic began as fraud, was developed as fraud and is now perpetuated as fraud…to “reform “it””?? Is that your charge?
          Chiropractic IS entrepreneurial-theatrics masquerading as healthcare for 123 years. The ONLY reform, like having eaten a bad clam…. is elimination.

  • Physiotherapy runs the risk of sliding into a conglomerate of unscientific methods. Fortunately, there is some resistance to this from one’s own circle. Recently I have been as well attacked as supported by physiotherapists in a somewhat heated discussion about a osteopathic-critical article. If the profession (I speak primarily for Germany) wants to maintain its good reputation, it must not succumb to the temptation of filling its portfolio with dazzling methods that attract uncritical audiences, but on the contrary strive for a good evidence base.

    In Germany, there is the initiative “Physio meets Science” from the circle of physiotherapists, which is highly worthy of support and actively tries to do just that.
    http://physiomeetsscience.com

  • Thanks for highlighting this issue in physiotherapy. There are many within the profession who are disappointed, to say the least, at the slow progress in moving physiotherapy forward.

    The biopsychosocial model of health is the direction that evidence from pain science suggests the profession should be moving in.

    https://bjsm.bmj.com/content/early/2018/07/17/bjsports-2018-099198

    Unfortunately there are still many physios who continue to use the older treatment modalities which you list. Many of these do come from the world of alternative therapy. Old habits die hard in some clinicians…

    • are you sure it’s ‘old habits’
      new physios are just as keen on woo, in my experience

      • New physios are keen on woo simply because the old woo that they have done has been proven not to work. Their normal “shake, bake and fake” is rubbish. Ultrasound doesn’t work, TENS doesn’t work, Wax baths, shortwave diathermy and exercises don’t work, Pilates exercises don’t work. So what is left? Nothing!!!!! They have to resort to methods of treatment that have evidence base, e.g. Spinal Manual Therapy.
        So, how many physios does it take to change a light bulb?
        None, because physios cannot change a thing.

        • GibleyGibley wrote: “they [physiotherapists] have to resort to methods of treatment that have evidence base, e.g. Spinal Manual Therapy”

          @GibleyGibley (long-time chiropractic apologist)

          In which case it appears that physiotherapists’ use of spinal manual therapy is (along with other providers) far more judicious than that of chiropractors. See Fig. 2 here:
          https://academic.oup.com/ptj/article/79/1/50/2857770

          This is likely the reason why:

          Quote
          “Chiropractors view the spine as an entity. Where they diagnose ‘subluxations’, they will normally manipulate and ‘adjust’ them (11). And ‘subluxations’ will be diagnosed in the upper spine, even if the patient suffers from back pain. Thus many, if not most back pain patients receive upper spinal manipulations. It follows that the risks of this treatment should be included in any adequate risk assessment.”

          Ref: Spinal manipulation for the early management of persistent non-specific low back pain — a critique of the recent NICE guidelines, Edzard Ernst, Int J Clin Pract (18th August 2009).
          Reference (11) is Ernst E. Chiropractic: a critical evaluation. J Pain Sympt Man 2008; 35: 544–62. Page 6 of the paper mentions a report that indicates that only 11% of all cervical manipulations are “appropriate” and gives the reference Coulter I, Hurwitz E, Adams A, et al. The appropriateness of manipulation and mobilization of the cervical spine. Santa Monica, CA: RAND, 1996:18e43.

  • I have excellent results from one set of visits to a physiologist. Of course this was a teaching clinic in a medical school where, I believe, the students would be receiving a 4-year degree. No woo there.

    Then I walk down a nearby street and see a clinic offering physiotherapy, reflexology, acupuncture and so on and I shudder.

    There still seems to be a lot of woo out there.

  • Good post Edzard. You picked a couple of fringe options that most physios have probably never been exposed to, let alone employed (Feldenkrais & craniosacral therapy spring to mind), and missed a couple of howlers that are still very common (electrophysical agents (sounds siencey, right??) such as ultrasound, laser, interferential & TENS – all don’t work for most if not all conditions studied), but the implication of your post holds true.

    It’s good to shine a light on the physio profession. Often their best defence seems to be “at least we’re not chiros” which is a very low bar to clear. The profit motive, the need to compete with other allied health practitioners (such as chiros, osteos, etc) as well as indifference definitely drives a lot of the shonky practices employed.

    If the regulatory boards such as the Chartered Society of Physios and Australian Physio Association started calling out clinics and therapists who used fake treatments, and eventually censured those who didn’t change, the profession would be in a vastly better position to cast aspersions at other healthcare professions.

    All of the above being said, there have been huge advancements in the way healthcare is provided cheaply and effetively thanks to physiotherapists performing very difficult scientific studies. Pain management (google scholar search Lorimer Moseley), tendon treatment (google scholar search Jill Cook & Ebonie Rio) and orthopaedic procedure decision-making are three areas enormously improved thanks directly to physiotherapist scientists.

    We are by no means perfect and have a lot of in-house cleaning to do, but established practice DOES change and we DO attempt to falsify the prevailing claims and practices of the profession. So the answer to your “WISHFUL THINKING OR TRUTH?” should be “It’s complicated.”

  • In regard to the professions, chiropractic and physiotherapy, this article may be of some interest. Especially the disquiet expressed amongst the physios as to their validity in treatment of a lot of conditions in comparison chiropractors.

    https://chiro-trust.org/advanced/chiropractic-physical-therapy/

  • In terms of individual practitioners offering woo provides profits. Pure and simple.

    In terms of the CSP they should be much more forthright in their condemnation of non evidence based treatments.

  • So since “leg checks”, “motion palpation”, x-ray analysis, AK, energy-imbalances, upper-cervical-misalignment, muscle imbalances AND EVERYTHING else used to determine the “target” for “manual-scamming” are all invalid, unreliable and spurious perhaps there could be agreement they are simply part of the entrepreneurial-trickery to ensnare the gullible into believing that there is “magic in my hands”. IF whackin ‘round on the gullible does offer some temporary quiescence of symptoms rationality would have us understand it as a “shallow” phenomenon not a mechanistically-profound one. A concept anathema to many PTs and virtually ALL DCs.
    But somehow “manual therapy” stands as the bastion of respectability for treating-away-pain….since it seems to have one iota of efficacy vs. none. Profound indeed.
    You pain-chasers are self-edifying, self aggrandizing entrepreneurs trying to play doctor….or god.
    It always sounds like the Christians arguing with the Muslims about how absurd the others’ beliefs are. Idiots all.

  • Edzard,

    If you are going to go after Physio minded practitioners, you need to get down to it, the osteopractors.

    https://spinalmanipulation.org/

    • I have done this many times on this blog and elsewhere

      • “Edzard on Saturday 15 September 2018 at 06:23
        I have done this many times on this blog and elsewhere”

        ~~~~~~~~~~~~~~~

        Please/Can you provide a link per your claim?

        • 2 different links were provided; you just need to click on the respective words

          • @EE
            “I have done this many times on this blog and elsewhere”
            Click on the Category “Physiotherapists”.
            4 pages and this blog is the first with Physiotherapy” in the title.
            Zero hits for osteopractor, osteopractic or James Dunning.
            Dry Needling gets 4 hits yet none are posted in or tagged physiotherapists.
            You have done many SR’s on acupuncture with some having dry needling in the key words going through Pubmed.
            Are they are in comments sections where we cite osteopractors? Links?

  • Dry needling and Myotherapy seem to be popular infestations of physiotherapy here in Australia. My wife left a physio practice because they started offering dry needling.
    On the other hand good physiotherapy has taught me how to self-manage cobditions, including one that cost me over a year’s work and threatened my career 30 years ago.
    Likewise good physiotherapy diagnosed a very painful condition I had a few weeks ago, taught me how to sooth it so I could cope and sleep, and helped again when I hurt another muscle doing an exercise wrongly.
    I think good physiotherapy enables patients to treat themselves and not have to keep coming back.
    I don’t know about the evidence base for standard physio or how good most physiotherapists are at handling new research results in a scientific way.

  • I suggested “academic physiotherapy today is strongly science based” or something similar recently in these forums.
    I’d still support this statement.

    I would also support Edzard’s statement that much of what many PTs actually do in the field is crap. This includes pilates, needling, spinal manipulation and all other assocated hussles. PT crap is as bad as chiropractic and osteopathic crap.

    At this point, I think science based PT is basically a behavioual discipline. That is, the interventions that demostrably work are focused on explaining the mainstream science of musculoskeletal probems, CBT and motivational interviewing, exercise prescription and adherence. Equally, if others such as chiropractors are moving beyond this list, they too are selling 100% pure bulshit.

    Personally, I spend much of my time explaing how individuals can navigate the health system at lowest cost, how health systems work, how health economics works, hierarchies of evidence, information asymmetry and plain old financial conflicts of inteterest in the health industry within the broad scope of PT practice. I routinely sit and explain peer reviewed evidence to patients.. It seems to be what many people actually want in a clinical setting. It comes under the rubric of PT patient education.

    Health economics and science provide a rationale for ditching the bullshit. And Im personally much more comfortable with economics and evidence hierarchies as placebo talk.

    In summary, teaching exercises is simple, and generally lots of different exercises are just fine. Encouraging self efficacy and adherence through 2-3 longish sessions over as many weeks seems to be about as much input as most people need.

    My 2c.

  • In recent years, more and more physical therapists have started to embrace pain science and the biopsychosocial model.

    In the process of adopting this mindset, rather than hold themselves accountable for all that they haven’t been able to offer patients, the biopsychosocial model has provided them with information that places more of an emphasis on the patient’s history and overall makeup. So for all of the good stuff that’s within the biopsychosocial model, physical therapists are still working within the confines of a certain business model that doesn’t allow for the highest tier of service (or the best possible results).

    Needless to say, physical therapists are using the biopsychosocial model as a smokescreen. By placing more importance on the biopsychosocial model, physical therapists have found a workaround that doesn’t allow for the bigger problems to be addressed. This allows for comfort, and of course, business as usual.

    As important as physical therapists pretend to be, in most clinics, the treatments are addressing symptoms and chasing pain. So of course, treatment takes much longer than it should.

    As broken as a physical therapist’s methodologies are, and have been for decades, longer treatment aligns with a business model that they’ve chosen to work within.

    Even if physical therapists had the knowledge, skill, and experience to get to the root cause in the shortest amount of time, it’s not humanly possible to provide the best possible service to multiple patients in the same space of time.

    When physical therapists throw a bunch of ridiculous stuff at something, given enough time, some of it is bound to stick.

    Dragging the treatment out just gives the brain more time to figure out how to find stability in positions that are less than optimal (i.e., protection).

    While physical therapists are busy pretending to do work that’s allowing for the best possible outcome, the part of the story that’s being left out is that patients aren’t capable of performing better than they were prior to the pain or injury.

    Since most patients don’t know what they don’t know, this practice isn’t likely to change any time in the near future.

    • So what would you suggest in place of a course of care with a PT?
      Chiropractic is a business model built on repeat visits if I have ever seen one AND they tend to offer many of the same modalities as well as supplements that are not necessarily science-based.
      Add to that, they often offer VERY expensive diet/nutrition programs that are also not well-founded…

    • Yep. Agree 100%.

      It’s primarily a business model problem. I came back to PT on a very part time basis about 2 years ago after many years of project management, consulting and executive roles mainly for large health ngos.

      I now mainly work as an academic teaching at medical schools after doing a non PT PhD..

      I like having some patient contact to “keep it real” from an academic perspective.
      I dont rely on PT for income. Which is very liberating business model wise.

      As i mentioned in my earlier post – i think at its best, contemporary PT is a no bullshit talking cure that can facilitate self efficacy. Further, PT has the distinct benefit of framing problems as physical, thereby removing much of the stigma of approaching pain and disability as emotional or mental health problems. PT opens the door to these discussions and appropriate mainstream referral.

      Another advantage of PTs is generally longer appointment times than GPs. It really is possible to cram a lot of useful advice and motivation in 45 minutes or an hour. But 2-3 sessions in total of this, with more often than not some OTC NSAIDs over as many weeks is usually all the face to face PT that most people need.

  • Richard, with all due respect, I think you have no idea what Physiotherapy is.

    This is exposed by the therapies that you tried to link to Physiotherapy.

    For Christ Sake, you said Applied Kinesiology is Physiotherapy. Are you crazy? The same goes to Reflexology… Christ.

    The Physiotherapists are the main critiques of Kinesiotape. Have you read the systematic reviews, made by (brazilian) Physiotherapists? Have you seen the results?

    Please, it might suit your personal marketing, but you shouldnt bash Physiotherapy for what it is not.

    Physiotherapy is an applied science.

    Go check PEDro database and find some useful MA , SR and RCTs.

    Cheers,

    Claudio

  • For back pain this is an accessible place to start – it largely replicates the themes in this blog IMHO.

    Cathryn Jakobson Ramin, “Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery”. Here is a brief review.
    https://nypost.com/2017/06/28/the-back-pain-industry-is-full-of-crooked-methods-book-claims/

    Ramin doesn’t much like chiropractors. Nor most PTs. Nor surgeons. Nor oxycontin prescribing physicians.

    Edzard – any thoughts on Ramin’s book? I assume you’ re aware of it.

  • Critical_Chiro wrote on Friday 21 September 2018 at 01:47 : “There are also superb researchers and reformers like Chris Maher, Paul Hodges, Lorimer Moseley, Mark Hancock (All Australian), Jan Hartvigsen, Bruce Walker, Christine Goetz, David Cassidy…

    @ Critical_Chiro

    Not everyone would agree with you there. For example, Jan Hartvigsen, in a recent slide presentation, appeared to make no mention of the chiropractic bait and switch (the majority of chiropractors are not evidence-based) or risks:
    https://rcc-uk.org/wp-content/uploads/2018/06/Jan-Hartvigsen_Royal-College-of-Chiropractors.pdf

    Christine Goetz was lead author of this recent appalling paper
    https://edzardernst.com/2018/05/new-back-pain-study-support-for-the-inclusion-of-chiropractic-care-as-a-component-of-multidisciplinary-health-care-for-low-back-pain/

    and David Cassidy, as you should know by now, is not to be trusted…
    https://edzardernst.com/2018/08/until-the-precise-risks-from-chiropractic-manipulation-are-known-patients-are-better-served-by-other-treatments/#comment-105139

    • As explained before re the JAMA military study, the design of the study was set by the government based upon how chiropractic is currently being used within the armed forces.

      • @DC

        I haven’t seen your previous explanation (please provide a link). From the paper itself (Supplement 1, trial protocol): “Responsibility for the conduct of the clinical trial described in this protocol is placed on the Palmer College of Chiropractic, in collaboration with RAND Corporation, the parent institution, and the Samueli Institute (SIIB). Please see the organizational chart in Figure 4.”

        Figure 4 (this blog doesn’t permit insertion of graphics) shows the ‘External Advisory Committee’ is the topmost-ranking overseer of the trial. The supplement provides the following details: “The EAC is comprised of six individuals who have all agreed to sit on the Board. These individuals represent leaders in either the research community in LBP, the chiropractic research community or in the military. They include the following individuals: Anthony J Lisi, DC, National Director Chiropractic Services, Department of Veteran Affairs; Valerie Johnson, DC, Staff Chiropractor, VAGLA, Department of Veteran Affairs; Dan Cherkin, PhD, Senior Scientific Investigator, Group Health Research Institute; Marion McGregor, DC, FCCS(C), PhD, Canadian Memorial Chiropractic College; Scott Haldeman, DC, MD, PhD, Clinical Professor Neurology, UC Irvine; Reed Phillips, DC, PhD, NCMIC Foundation.”

        Will you kindly explain which of these individuals represents ‘the government’? Does he or she come from the legislative, executive, or judicial branch? You see, it seems to me to be a most unusual circumstance where — even when the military is involved — a national government ever takes a direct interest in the detailed conduct of a clinical trial, particularly when they’re not even funding it, directly or indirectly. The paper explicitly states the funding came from the RAND Corporation, which certainly receives money from the US government, but also from many other sources.

        At the moment your comment seems to be based on extremely economical use of the truth.

        • This trial was funded by Department of Defense Office of Congressionally Directed Medical Research Programs, Defense Health Program Chiropractic Clinical Trial Award (W81XWH-11-2-0107).

          • Yes, but that doesn’t mean the design of the study was in any way set by the government!! Do you chiropractors have no idea how research grants work? The (pragmatic) design of the study will have been set by the investigators and contained in their grant application. They’ll have submitted a proposal which was accepted for funding, but once granted, it was all in their hands. Which government official do you imagine oversaw the research?!

            The publication tells us precisely who handled the trial. I’m making no comment about the quality of the research — others have already done that. Just that when you say “the design of the study was set by the government” you’re talking horse manure. It’s very sad if you can’t see that, and that you’re trying — absurdly — to invoke the highest possible supporting authority for this trial, in an attempt to elevate its status.

          • Several meetings took place with the involved parties before the application was even submitted. No, i dont have access to those notes, I’ve only had conversations with several of the lead investigators.

            But sure, the researchers elected not to include shams in this part of the study even though they did in ACT 3 (asymptomatics) because they just didn’t know better.

            Or, could it be that we are in the midst of a freaking war and the DoD didnt want us doing a sham procedure on symptomatic active military personnel? Nah.

            All this shows is how low some people will go to try and discredit a profession which is trying to help with the some of the highest disability burdens we face.

            Sad.

          • “Because chiropractic care for LBP in the military is delivered within a multidisciplinary framework of care, rather than as a single system of care, the study is focused on the comparative effectiveness of chiropractic care plus usual medical care with usual medical care alone, in a pragmatic design.”

            https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4746780/#!po=9.05797

          • Sorry, DC, your attempts to add authority to what has already been described as a lousy study by claiming the study design was “set by the government” is simply not working.

            The trial was funded by the RAND Corporation, to whom the principal investigator(s) will have submitted a grant application. Even the W81XWH-11-2-0107 document states “The views, opinions and/or findings contained in this report are those of the author(s) and
            should not be construed as an official Department of the Army position, policy or decision
            unless so designated by other documentation.” Please try to get a feel for how research gets funded.

          • So it wasn’t funded by the DoD even though they say it was funded by the DoD?

            “This trial was funded by the Department of Defense Office of Congressionally Directed Medical Research Programs, Defense Health Program Chiropractic Clinical Trial Award (W81XWH-11-2-0107).”

            https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-016-1580-1

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.

If you want to be able to edit your comment for five minutes after you first submit it, you will need to tick the box: “Save my name, email, and website in this browser for the next time I comment.”
Recent Comments

Note that comments can be edited for up to five minutes after they are first submitted.


Click here for a comprehensive list of recent comments.

Categories