It’s been interesting this week to hear from physiotherapists who share my concern for the kinds of objective, detached, depersonalised ways that physiotherapists often project their professional practice identities.
I think, as a profession, we’re starting to understand some of the important reasons why we do this (we want to be considered professional, scientific, evidence-based, etc.), but it would be nice if we could also see more of the barriers to progress that these discourses are creating, and discuss whether there might be some value in thinking otherwise.
I’ve developed, led and taught a 1st year UG paper called Therapeutic Touch for over a decade at AUT, and in the paper we introduce the students to the basics of Swedish Remedial Massage (effluerage, petrissage, etc.). But the paper also has an overt focus on helping the students negotiate appropriate touch with their clients/patients. Its far removed from the way I was taught massage, where everything was about the acquisition of technical skills and there was little thought given to the person you were massaging. Thankfully those days are gone, but the echoes of some of the same detached, dispassionate practice remain.
You see it most profoundly in the way that musculoskeletal physiotherapy has become focused on batteries of tests and measures and technical remedies focused on acute, often self-limiting injuries. This is really evident in New Zealand, where around 60% of physiotherapists work in private (musculoskeletal) practice. The proportions are higher in NZ than in many other countries partly because we have a no fault compensation system that funds the medical and rehabilitation costs of any accident (see ACC).
This partly explains why New Zealanders have been real innovators in the field of musculoskeletal physiotherapy. But like all other developing countries, we too face an ageing population of people living with multiple co-morbidities longer than can be sustained by our health system. In all likelihood, the future for physiotherapy will not be in the management of acute, musculoskeletal disorders (or if it does, this will be fully privatised and only available to those who can afford to pay for it). The greatest need by far is for skilled, trusted, relatively low-cost, high-value practitioners to work with people with complex, multifaceted health problems, and physiotherapists are ideally placed here. If only we could become a bit less rigid, a bit more ‘holistic,’ and a bit more humanistic.
The irony is that most good, experienced and popular physiotherapists have learnt how to go beyond the technical rationalism of their training and become more embodied practitioners, but they have had to do this despite their training and professional scope rather than because of it. We’re seeing the emergence of this more holistic approach in the rise of the pain specialist in NZ and elsewhere, for example, and these people are making a real difference. But until recently, those that have succeeded have often felt that they have had to betray their profession identity to get there. To give an example;
A friend of mine was recently asked by the local hospice to treat a couple of people who were in the end stages of cancer. Having talked with the staff and met a couple of the patients, she decided that her role was palliation; making the residents as comfortable as possible in their last days and weeks. She decided to offer general massages to anyone who requested it. She had one resident who had lung cancer, and she treated her for three weeks before she died. The technique was nothing special – some general slow effluerage over her back, shoulders and arms (for which there is absolutely no evidence) – but during the ‘treatment’ session, my friend told me that the resident was transported away from her pain. For the 45 minutes or so of the treatment, she let go of her fear and suffering and lived, all be it for a short time, in comfort. Sometimes she cried, sometimes she talked, sometimes she just lay silently. The therapist just listened and massaged.
You would not believe how many people criticised her for massaging people with end-stage cancer (what’s the point, one person said); for using ‘outdated’ methods (massage); for having no physiological rationale for her treatment. My friend asked one of her colleagues what she would have done, and her suggestion was to leave it to the nurses and concentrate on things that were likely to show a better outcome.
But it seems to me that this is exactly the kind of sensual practice that physiotherapists need to engage in if they are to understand the possibilities of the new economy of health care. So what if there is no evidence-base for this kind of treatment. I would much rather think of physiotherapists practicing in this way than the way we saw in the video in the last post. To me, the idea that people are just machines to be diagnosed and fixed; moved around like carcasses without care or compassion, is deeply offensive.
There is a banal, casual and cynical wrong-doing going on in physiotherapy that passes as skilled practice. It is sanctioned by our ethical guidelines, our professional bodies and our physiotherapy schools and, if we’re not careful, will be the undoing of the profession.
David,
You’ve nailed it again. Our Western affluent economies have been able to withstand the biomedicalization of pain predicaments for the last several decades purely due to a seemingly unlimited amount of public resources (read: “taxes”) coming into the coffers. Well, a perfect storm of aging baby boomers and precarious global economics and security challenges is going to put a massive strain on this “business as usual” approach to treating patients with chronic conditions, like persistent pain, that are complicated by aging. At some point, the money is going to run out. PTs are well-positioned, as you mentioned, to have an important impact on stemming the the deleterious effects on individuals dealing with the impairments and disabilities that can arise from a pain predicament that has gotten out of control. Unfortunately, it seems we’re more interested in advancing our professional turf and prestige among our medical peers than coming up with more effective and rational ways to help our patients.
Like you, I’m troubled that this attitude could lead to the profession’s undoing.
Thankyou so much for your thought provoking and encouraging words. I am a physiotherapist working with COPD patients most in the end stage of their lives. I have watched and observed how my hands just with gentle pressure on a rigid thoracic cage can soothe , settle and improve breathing rate and depth and my patients feel reassured and report the differences. I find it hard to write in my notes what I have actually done even though there is a objective measure in regards to breathing rate and SPO2 levels as feel others who may read them will think I havent practised treatment that has been proven to work. Yet I receive many medical referrals to help those that are pallative. I still find percussion and “vibes” work well and the people I work on ask for them over and over again. I am so grateful for your writings Thankyou Lindy Campbell Respiratory Physiotherapist
Yes it is timely. When I teach I always ask the group why did you get into this profession and how far have you strayed from that point? Most of the patient/clients I see in and outpatient hospital based setting and in my own private practice are persistent pain conditions. I absolutely agree that we need to grow and instill and allow in the physics a deeper, more caring and compassionate approach that allows for a deeply felt connection through touch. Our emotions are embodied in the tissue of our body and we know now that healing of trauma occurs with a deeply felt somatic experience shepherded by a caring touch. We have strayed so far one therapist mentioned to me “that I forgot the meaning in my work. I became an automaton to the “three citations rule” before I deemed what I did as ok”. I do not practice like I did 10 years ago and I am not concerned with Evidence Based Practice. Persistent Pain has many facets and the one we need to connect with is the human spirit. Why would we want to quantify that??
Oops Typo “Physios” not physics
I enjoyed both the articles and the comments. We, as humans, are built to touch and to be touched. This has been studied in both primates and human beings. Having worked in most areas of physiotherapy, I would have to agree that one of our most profound effects comes from caring, sensitive touch. I often will reassure a new client, who wants to be a “good” client and is having some difficulty relaxing initially that their body and tissues are getting acquainted with my hands and tissues and that this trust takes time and communication. Those with persistent pain have treatment needs that do not necessarily fit in a nice little diagnostic box. The experience of pain is both psychological and physical. If mankind can vary anatomically, which is the norm, not the exception, how much more will the psychology which is individual? I would suggest that physical therapy has aspects of “soft science” and embrace them rather than deny them.
Thanks so much for this post and your perspective, David! There is a small, but growing, group of us physical therapists who have been integrating yoga therapy into our practices for over a decade, and in some cases 2 or 3 decades. We all have experienced, and continue to experience, many trials and tribulations. It is an ongoing challenge to find a way to deliver the holistic (biopsychosocial) aspect of care that is still within our scope of practice and also that is accepted not only by our medical peers, but also third party payors. But we are supporting each other with creative and innovative approaches and making steady progress! This 2min video is very fitting for what you are speaking of; I wish every health professional would watch: Editor-At-Large (self proclaimed EBM/RCT advocate–changed his tune), George Lundberg’s recent video: “The Proper Study of Me is Me: A Clinical Trial of N of 1”: https://www.youtube.com/watch?v=SwDQJ1LQ69k