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Oct 24, 2017

Since when have physios stopped putting their hands on patients? Since when can you assess someone in 10 minutes? 10 minutes, either face to face, or over the phone, does not give you enough time. It means corners are cut, assumptions are made, features are made to fit at the exclusion of others. Who loses out? Firstly – the patient. But also the physio. How are they progressing their practice? Do they have a mentor? Someone who can help their career and profession, not just enhance their monthly salary. Where has clinical reasoning gone? Where has the differentiation tests gone?

I’m sorry, I have slowly been getting more and more annoyed and disappointed when I hear increasing tales of how clinical practice is changing – this is not, let me be clear, a private vs NHS discussion. Far from it. I know of plenty private practitioners who are assessing/ treating in 15 minute slots, who are repeating the same treatment over and over again in spite of the patient reporting no change or worsening symptoms.

How do I hear this? Primarily, from patients who see us, often after a negative first experience, either in how they were spoken to, assessed, or treated. Patients are knowledgeable, informed and they know their bodies better than anyone, and invariably, they know what they need. They have insight, they have goals and expectations and if their expectations are not met then you usually have an unhappy patient. They know when they are being fobbed off or treated the wrong way .They know when they are spoken to like a child or in a condescending manner.

What’s going on? Firstly, guidelines. What are they? First and foremost, they are not rules or protocols, but recommendations of effective treatments formulated after research. They also look at the most cost effective way to treat patients . NICE guidelines are the most well known. Whilst they can give insight and guidance to physiotherapists, I judge them as that. I feel fortunate that I have my own private practice. This allows me to assess every patient as an individual, not ‘shoehorning’ everyone down a path that isn’t right for them. Take low back pain. Research now suggests that hands on physiotherapy is not indicated for non specific low back pain. Yet, we see in practice, patients improving, and symptoms resolving – not just from the hands on techniques which may mobilise stiff joints, but from the advice we give, the practical solutions to gaining back normal movement and avoiding a downward painful spiral which sees patients fearful of moving, concerned something will happen if they lift or move the wrong way.  It is not just what we do with our hands, although the power of touch/ hands on should not be underestimated. It is not necessarily about choosing the right ‘technique’ but with what else goes on in  that treatment room – how we speak, how we gain rapport, the information we give, the exercises. Most of this would be impossible to measure in a randomised controlled trial.

As a physio, our profession has changed and will continue to change. When I was a student, we still used inductothermy (think huge tubing attached to a machine which looked like it belonged on star trek), wax baths (infection control would have a field day), and faradic foot baths (basically an electric current passed through water to stimulate muscles – what could possibly go wrong).

I am pleased we continue to progress, but I sometimes feel whilst our list and citing of the latest ‘evidence’ all sounds very impressive, we also need to remember that evidence based medicine also incorporates clinical expertise and patient values and preferences. 15 years ago, patients got better with manual therapy and physiotherapy. How can all that suddenly be wrong? In my opinion, it is often because providers want patients seen and discharged within 1 to 2 treatments. Often patients are not assessed, but given a sheet of exercises or sent something in the post.

We now know that outcomes are not just based on the diagnosis, but on that patient’s beliefs, their understanding, their previous experience of pain and pathology, their personality type, their job, their past medical history, their sports/ hobbies. The list is almost endless.

At Taylored-fit Physio,we pride ourselves in seeing each and every patient we see as individuals with their own pain story or injury tale. We listen, we examine and we treat as appropriate. We re-evaluate at every session and we modify what we do if things are not progressing as we would expect. But, we also get to know our patients. We know Jackie has a wedding to go to and would like to wear her high heels, we know David wants to get back to golf, we know as well as low back pain, Audrey has previous history of anxiety and depression and knows this also contributes. We get you, we understand you.

To continue to be the best physios we can be, yes, we need to listen to research, but we need to listen to our patients, use our clinical expertise, experience, and at every session, re-evaluate.

If you are a physio reading this, I hope your clinical practice is progressing and your outcomes are good. If you are reading this in a position that you either have had physio or are thinking about physio – choose wisely. If you are not being treated with respect, professionalism and with appropriate treatment or you are not getting the outcome you expect – ask questions and be confident. It should make no matter where or how you came to see a physio. What should matter is how you are treated.

Thank you for taking the time out of your day to read this.

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Vicky Smith