Is physiotherapy blog too cynical?

I wonder if this blog is too cynical when I look at some of the other offerings out there. I set this blog up in response to the lack of blogs physical therapy blogs and the few "physiotherapy" blogs out there seem to be written by people still in love with the profession and its ideas. I can see a lot more of the shortcomings in physiotherapy than they can. Some physiotherapy material seems to be an extension of the treatment room with therapists offereing advice about exercises and treatment. I heard the other day about a site (and i don't know the name) which sounds a con. For a certain amount of money it is supposed to be possible to enter a health problem and the online clinician will give professional advice and a diagnosis. Guess they must be heaps better then me to be able to give out advice to unseen individuals with vague problems and then charge them for it! It stikes me as a bit of a risk because there is no regulation of the internet and anyone can set up a website in a country which does not have any regulations of physical therapy and then take whatever money they want for dealing out any old trash for advice. The internet is cool for finding large amounts of info but poor for ensuring the quality of the info. It's all down to the individual to be careful.

Autonomy of the physiotherapy profession

I've read today that we've just passed something of a milestone for the autonomy of physiotherapy in the UK. According to Frontline it is 30 years since the British Department of Health made the first moves towards giving physios autonomy. I'm not quite clear about how some people link this with patient self referral in the NHS. The profession has had true autonomy for a number of years but this has existed in non-NHS independent healthcare. This idea of NHs self referral is not primarily an issue of autonomy but about the way free physiotherapy is accessed. It's not autonomy that's the issue but NHS housekeeping arrangements. Allowing everyone to refer themselves to an NHS physio puts local NHS departments in direct competition with private healthcare facilities but I don't suppose that in too many parts of the UK self employed physios will be losing sleep over it. Many NHS physiotherapy departments have long waiting times and opening themselves up to self referral will make no difference to the public.The service will remain effectively inaccessible. If you have to wait 4 or 5 months to be seen on the NHS for an acute problem it will make no difference if your GP decided to send you or if you decide to take yourself there.

Ultrasound

On the TV this week I saw a sports physio doing ultrasound to an injured calf muscle and I was interested in the technique being used. Whilst he talked to the camera he wizzed the treatment head round at a speed the same as if he was mixing a cake. I'm not sure this was how he learnt to do it and if the technique was changed for the sake of the camera but it would be interesting to know how effective it was. Any area of injured tissue would have received the briefest of exposure to the ultrasound waves. However it made me think about the use of ultrasound and the way it was developed. I wondered if the physio was afraid of setting up the dreaded cavitation effect in the tissues but if you want to know more about this dread effect you will have to trawl the folklore of the profession as I expect nobody has actually done the "R" word on it [research]. Please correct me if I'm wrong but I think it's all based on a limited number of in vitro tissue studies and very little on the adverse effects of ultrasound has been done in the clinical situation. No doubt the athlete receiving the treatment felt better for it but was this because someone was seen to be helping him rather than the fact that sound energy actually reached the site of injury and even if those magical soundwave got there, does anybody really knows if they make any difference to the healing?

Trade unions and professional bodies in physiotherapy

From the outset I should make it clear that the contents of this blog are a personal view (and one that is in a state of devlopment). One of the things I've often wondered is whether British physios' best interestes are being served through have their professional body and their union all within the same organisation. It's easy to assume that because things have always been done in a certain way then that is the way it should continue into the future. The CSP generally does an OK job as a union but it's strength lies more in being a professional body. As a union it is rather small and therefore cannot act in a unilateral manner when it comes to members' interests.And which member of the public has ever heard of the CSP? I think that CSP members should ask questions about what they want from a trade union and how this differs from a professional body. I'm not saying this because the CSP does a particulary bad job at being a union but what I would like to know is whether another way of doing things would be a lot better for physios. A cause for hesitation is occupational therapists. Their professinal body and unions are separate yet this does not seem to make any marked difference to them. Another cause for caution is the reality of NHS pay and conditions bargaining. There is unlikely to be much more on offer to a profession regardless of whether they are independent or members of a big union. I think it's always a good idea to look at dfferent ways of doing things but I'm not sure if change would produce any benefits but it's something we should be open to. I have never even heard it spoken of before.

Are physiotherapists flat earthers?

Are physiotherapists flat earthers? This question can be taken in two ways. Are physios people who believe the earth is flat? No. Are physios people who persist in a set of beliefs even though there is evidence to the contrary? Yes, but in physiotherapy this has some interesting dimensions.A major element of believing the earth is flat is the inability to think outside the box and the box I am refering to is the box of belief about the way that the profession does things. The flat earth thinking is unable to see that many of the things which are assumed to be obvious are in fact products of time and place, constructs which are limited in their universality. This applies to professional standards, clinical practices and theoretical models. It is possible to assume that standards, at present upheld as "best practice" might be unrecognised in other parts of the world, or be unrecognised within one's own country at a different time. One of the things which bugs me is the good old pain gate theory, now way past its shelf life but still being promoted. This as an example clarifies my arguement. The reason that physios talk about the pain gate is because they cannot think outside the box, cannot think bigger than this rather creaky old theory.

Sometimes I feel very alone thinking all these ideas (can't you hear those violins?) Looking at Frontline (new out today) I feel the twice monthly heartsink I get from the magazine when I read the course listings. The profession seems very willing to give up large amounts of time and money to learn ideas and techniques which have minimal proof. I might be alone in this belief but it occurred to me a long time ago that the sum of local knowledge and skill is worth more than the majority of courses which are run. It is important to implement ways of capitalising on local skills and knowledge both through effective continious professional development and through effective sharing of knowledge but it is more valuable than most weekend courses. Sometimes on the news you hear that the combined experience of a group of professionals is..... (last time I heard it was in realtion to a team of firefighters). Apply this to physiotherapy. Many physios will be working in teams or orgainisations with the combined experience running into many years yet they want to go on courses to listen to highly polished presentations from someone with only a small fraction of the skill and experience. The assumed authority of the course tutor is the key but this is a false assumption. It's time we stop being intimidated by these self appointed gurus and set up organised ways of both developing our own skills and capitalising on our corporate ability. Lets' stop thinking that the only way to devlop skill is to pay loads of money for a weekend course.

evidence based practice or practice based evidence?

I did not finish yesterday's rant so here is the next installment. In the car today I caught part of a really interesting discussion on Radio 4 which was about obesity research. The academic was saying how that within obesity research there is a trend being led by Government to drop high quality search in favour in favour of what was called "practice based evidence" because producing high quality research was too difficult. The academic said that practice based evidence is not evidence, yet it rang loud and clear with me because so much of what passes off within physiotherapy as "clinical effectiveness" is the same stuff, so-called evidence of effect produced from everyday practice. One of the big flaws which has crept into the profession is the use of sloppy outcome measures, adopted because they have the magic word "validated" attached to them yet often inappropriate to what needs to be measured or able to show change but unable to demonstrate this was as a result of physiotherapy (why is there always the assumption that all we need to do is to demonstrate change in the right direction on an outcome measure?) I have big problems with MYMOP, an increasingly popular measure with physios, popoular because it can be used in a wide range of circumstances but something which fails to make common sense. It's a bit like measuring patient satisfaction, the measure of which is usually high for most (therefore by assumption are we all doing a good job even whan there is evidence to the contrary?) I also have reservations because an outcome measure can achieve validation in statistical terms but does that then mean it is always going to be useful within clinical situations very different from those in which it was developed? Am I talking about staining the limits of validity?

As usual I've got more questions than answers but I thought that's part of the reason for having a blog.

physiotherapy evidence and clinical education

I've noticed something interesting within physiotherapy but I'm probably stating the obvious. There's a conflict between those who want to practice according to the best evidence available and those who argue that results and experience are more important. Arguably research evidence and experience go together, but I sometimes get bothered that despite 10 years or more of evidence based practice there 's a large number of British physios who seem too willing to be taken in by the lateast ideas when these new ideas or treatment techneques are promoted by eloquent trainers running weekend courses. Now that evidence based practice is a comfortable term , when you go on any clinical course the course tutor will always throw in how the course content is evidence based and it will do X,Y and Z if you use these techniques. There will usually be a heap of research discussed but what the course tutor will conveniently avoid is presenting sound clinical trails which show the techniques being taught can actually make people's health better in a way which is more effective than the "healing effect" of time or the power of positive thinking. The research "evidence" is evidence by proxy, usually within a related area but never actually about the techniques themselves. Then there's the inevitable using the techniques on one's fellow course participants, and leaving the course ready to be let loose on patients.

I wonder if part of the problem arises from a deep seated desire in many physios to believe in themselves, a need to believe that what they are doing is valuable, effective and skillful and perhaps an inability to deeply question something in which there is a big emotional investment. To allow for the possibility that the majority of patient recover through natural healing processes or through their thought processes is difficult. This would mean that complex "skills" requiring time and money to learn are in reality worth very little, an uncomfortable thought if you have sacrificed financially, something which also creates a feeling of insecurity at work ("if patients get better through natural recovery how can I be worth £25 000 per year?") Yet to question things in this way would be the start of something much better within the profession and for us as individuals. If we had the courage to abandon so many dubious clinical practices we could then put every effeort into those things which really do make a difference. Then we wouldno longer have to go on weekend courses which cost heaps of money to obtain a course certificate which is of dubious value.