Physiotherapy. Scientifically Sound?

[Thor 2]

I have not had a good experience at the hands of physiotherapists and I wonder if the treatment is scientifically sound.

My experiences:

1. Was referred to a physiotherapist after doing something to my upper back and neck. After 3 treatments there was no improvement. The physio guy spent much of his time telling me that manipulation, as done by chiropractors and such, was BS. I went to a GP, recommended by a friend, who did manipulation. In 5 minutes the doc cured me.

2. I hurt my shoulder and arm in a skiing accident and was referred to a physiotherapist. Treatment gave me no relief that I noticed and I doubt it accelerated my recovery.

3. When my office chair collapsed two weeks ago, I suffered bruising around the spine. My doctor suggested I get physiotherapy, although I had been improving. I suffered more pain during this treatment, than I have for some time. I don't think I will go back.

There are many years between these experiences.

[EHocking]

Anecdotally, myself, family and friends have found that sports physiotherapists seem to be more skilled and less woo than the non-sports variety. Sports physiotherapists have to undertake post-graduate specialist study which tends to focus more on physical science.

Yes it is not unlikely that they’ll suggest acupuncture for pain relief, but they are much less likely to suggest reiki as a treatment or attempt back-cracking woo like a chiropractor would.

[Thor 2]

Originally Posted by EHocking

Anecdotally, myself, family and friends have found that sports physiotherapists seem to be more skilled and less woo than the non-sports variety. Sports physiotherapists have to undertake post-graduate specialist study which tends to focus more on physical science.

Yes it is not unlikely that they’ll suggest acupuncture for pain relief, but they are much less likely to suggest reiki as a treatment or attempt back-cracking woo like a chiropractor would.

Quite a few years ago I would, not infrequently, get some problem with my back and neck. I found relief with the manipulations done by chiropractors and the doctor I mentioned above. I am skeptical about the claims chiropractors make about curing all manner of maladies, from indigestion to ingrown toenails, however.

[arthwollipot]

Originally Posted by Thor 2

Quite a few years ago I would, not infrequently, get some problem with my back and neck. I found relief with the manipulations done by chiropractors and the doctor I mentioned above. I am skeptical about the claims chiropractors make about curing all manner of maladies, from indigestion to ingrown toenails, however.

It's been said that what is unique to chiropractic doesn't work, and what works is not unique to chiropractic.

I would, broad brushstrokes, trust physiotherapy. Hospitals generally have a physio department, just like they have a radiography department and a surgery department and a maternity department. I'm seeing the physiotherapist at the hand clinic again early in the new year and I expect them to help with my recovery greatly. Heck, they already have and I've only seen them once so far.

[Chanakya]

Originally Posted by Thor 2

I have not had a good experience at the hands of physiotherapists and I wonder if the treatment is scientifically sound.

My experiences:

1. Was referred to a physiotherapist after doing something to my upper back and neck. After 3 treatments there was no improvement. The physio guy spent much of his time telling me that manipulation, as done by chiropractors and such, was BS. I went to a GP, recommended by a friend, who did manipulation. In 5 minutes the doc cured me.

2. I hurt my shoulder and arm in a skiing accident and was referred to a physiotherapist. Treatment gave me no relief that I noticed and I doubt it accelerated my recovery.

3. When my office chair collapsed two weeks ago, I suffered bruising around the spine. My doctor suggested I get physiotherapy, although I had been improving. I suffered more pain during this treatment, than I have for some time. I don't think I will go back.

There are many years between these experiences.

Haven't really "studied" the question, but a friend is physiotherapist. I think it's no more (and no less) than focused 'exercise science'. Not rocket science, not by a long shot, nor even full-on medical science, but grounded in science for all that (as opposed to chiro, that's "grounded" on a mix of science and woo, so that the end-result is simply woo, that sometimes works.)

Short story, my take: Physiotherapy is (to my limited knowledge) based squarely on science. A good, humble, conscientous physiotherapist, who suffers from no delusions about the scope of what they can do, and who scrupulously checks back with actual doctors on things that are beyond them -- which, as far as I can tell, my friend does -- should be able to do some actual good.

[Modified]

I'm not saying it's useless, but typically, the amount of physiotherapy you need will be exactly the amount that insurance will pay for. This is an incredible coincidence.

[SusanB-M1]

Having been very wary of chiropractors for a long time, homeopathy, etc, I rely on physios and exercise. After being knocked down by that car in 2014, I thought my hip might need replacing, but the GP said to avoid an operation if at all possible and, as the injuries, which had not needed surgery, healed, I went to an excellent physio. She told me what exercises to do and, because I followed them, my strength and mobility returned. There is still the same wear and tear which was there before, but nowadays I don't even have to think of a hip op. As she said, 'people say that the exercises don't work ...' and I finished the sentence for her, '... because they don't do them!'

As it happened, the driver's insurance paid for the physio, but I would have paid for them if necessary - well worth it.

[Squeegee Beckenheim]

The biggest problem with chiropractic is that it can lead to death. That was published 10 years ago. There have been more cases since then, including high-profile ones like the model Katie May. What's more 30-61% of all patients experience at least mild adverse effects, but with the possibility of non-fatal adverse effects including strokes. And these things are vastly under-reported (close to 100% under-reporting), making it impossible to determine a rate of serious adverse effects.

So it's not just that it's woo based on religious and spiritual beliefs, although it is (its founder literally called it the "Chiropractic Religion"), it's that it's dangerous woo based on religious and spiritual beliefs, with the practitioners actively working to cover up the danger.

[Carrot Flower King]

Originally Posted by arthwollipot

It's been said that what is unique to chiropractic doesn't work, and what works is not unique to chiropractic.

I would, broad brushstrokes, trust physiotherapy. Hospitals generally have a physio department, just like they have a radiography department and a surgery department and a maternity department. I'm seeing the physiotherapist at the hand clinic again early in the new year and I expect them to help with my recovery greatly. Heck, they already have and I've only seen them once so far.

Pretty much what Arth said.

Chiro, in its pure form, is flat out woo and, as pointed out, has potential dangers.

Physio is better and tries to stay attached to real anatomy and decent medical principles.

However, individual physios (see also comments I have made in many places about my fellow nurses and also OTs and medics) can be as woo prone, lacking in basic statistical knowledge, unable to assess evidence and research, flat out unscientific, if not anti-scientific, as any of the rest of the population. One local physio was told by Carrot Flower Queen to go forth and multiply for suggesting acupuncture. Their reply was along the lines of a lot of people like it, which got a further response about flies and faecal matter.

Overall, I take individual physios as they come (all the ones I've met were sensible), but chiro can go a long way away and carry on going...

Disclaimer - both my parents were physios, but if they'd been eejits I'd say so.

[Carrot Flower King]

A couple of other points...

Quite a few of the things for which folk may be referred for physio may fall into the "not terribly specific and may be self-limiting" category, lacking the external, objective evidence of something like an X-ray.

My mother, in her working on ward days especially, would point out that she mostly had to get folk to do things they didn't want to (as it hurt), in ways they didn't want to (as it hurt), at times they didn't want to (as it hurt), but which were all needed for any class of successful recovery. This did not always make her immediately popular and did lead to things like several members of a knee rehab group (all hard Durham miners, some of whom objected to being told what to do by a slip of a girl from Waterhouses, especially a teacher's daughter - yes, the Deerness Valley was like that) declaring, in my presence, that she'd been trained by the Gestapo.

[Darat]

Originally Posted by Carrot Flower King

A couple of other points...

Quite a few of the things for which folk may be referred for physio may fall into the "not terribly specific and may be self-limiting" category, lacking the external, objective evidence of something like an X-ray.

My mother, in her working on ward days especially, would point out that she mostly had to get folk to do things they didn't want to (as it hurt), in ways they didn't want to (as it hurt), at times they didn't want to (as it hurt), but which were all needed for any class of successful recovery. This did not always make her immediately popular and did lead to things like several members of a knee rehab group (all hard Durham miners, some of whom objected to being told what to do by a slip of a girl from Waterhouses, especially a teacher's daughter - yes, the Deerness Valley was like that) declaring, in my presence, that she'd been trained by the Gestapo.

Physiotherapists are sadists, everyone knows that!

[Carrot Flower King]

Yup, it's true.


Oh, certainly here in the UK physio training syllabussesssssssss should be available on line via the various colleges/universities providing the training or else via the Chartered Society of Physiotherapists, so anyone interested can look.

[angrysoba]

I think it really depends on what the problem is.

Are these things that would have got better anyway? If so, who knows what role any intervention played.

What did you actually do in each case?

For example, if you broke some bones and were more or less immobilized then surely some exercises that you did while recovering would be worthwhile.

In fact, it seems likely that over-reacting to an injury and either assuming it that doing anything could make it worse, or increasing your anxiety about moving things is likely to end up being bad for your recovery.

Two physicians who have a barbell lifting podcast and You Tube channel that I watch/listen to fairly regularly caution against anyone (whether they are chiropractors, doctors, physiotherapists etc...) who make claims about how your specific posture or faiure to correct "asymmetries" etc... can lead to disaster.

They point out that such claims can lead to a nocebo effect - which is similar to a placebo except that the invoking of a nocebo leads to bad outcomes simply by making you think about it more.

Their advice, assuming that we are not talking about some kind of very serious injury, is that you should basically lift barbells and forget about it. The pain will go away and you will get stronger.

[Carrot Flower King]

Here's a link to one of the CSP's pages on UK-ian evidence-based guidelines: https://www.csp.org.uk/professional-...based-guidance

The CSP's site does have a load more stuff, but a lot appears to be members only.

NICE will have other bits about guidance on EBP.

[smartcooky]

Originally Posted by Thor 2

Quite a few years ago I would, not infrequently, get some problem with my back and neck. I found relief with the manipulations done by chiropractors and the doctor I mentioned above. I am skeptical about the claims chiropractors make about curing all manner of maladies, from indigestion to ingrown toenails, however.

I used to have a long term problem with a severe, chronic pain in the back of my right knee. I used to take pain killers for the worst of it. Went through the same rigmarole as you (GP visit who gave a physio recommendation). Several visits to the physio for manipulation and massage of the back of the knee joint as well as heat treatment. No results, and the pain, if anything, got worse. Eventually the pain would go away on its own, but within a few weeks or months, it would always come back. This went on for a few years.

Finally, a friend recommended a local chiropractor, so I went. The chiropractor said the physio was treating the wrong thing. My knee was not the problem, it was my lower back. I had a pinched nerve in an area known as "the horse tail" - it had a fancy Latin name I don't recall - a bunch of nerves in the lower back. She said what I was feeling was "reflected" pain, the nerve being pinched was being felt as pain at that nerve's ending point behind the knee. First session on the drop table and the pain reduced dramatically. Two further sessions on the drop table over the next two weeks and the pain disappeared entirely.

I have been pain-free ever since. and that was over 20 years ago.

PS: Its worth noting that the chiropractor said the physiotherapist should've been able to work this out himself when it became apparent that treating the knee was not working, and had the physio done their job properly, he would have been able to alleviate the pain and I would probably have not ended up needing to visit her. I was rather annoyed by this because it meant in all probability that I had been putting up with that pain unnecessarily for years

[Thor 2]

Originally Posted by smartcooky

I used to have a long term problem with a severe, chronic pain in the back of my right knee. I used to take pain killers for the worst of it. Went through the same rigmarole as you (GP visit who gave a physio recommendation). Several visits to the physio for manipulation and massage of the back of the knee joint as well as heat treatment. No results, and the pain, if anything, got worse. Eventually the pain would go away on its own, but within a few weeks or months, it would always come back. This went on for a few years.

Finally, a friend recommended a local chiropractor, so I went. The chiropractor said the physio was treating the wrong thing. My knee was not the problem, it was my lower back. I had a pinched nerve in an area known as "the horse tail" - it had a fancy Latin name I don't recall - a bunch of nerves in the lower back. She said what I was feeling was "reflected" pain, the nerve being pinched was being felt as pain at that nerve's ending point behind the knee. First session on the drop table and the pain reduced dramatically. Two further sessions on the drop table over the next two weeks and the pain disappeared entirely.

I have been pain-free ever since. and that was over 20 years ago.

PS: Its worth noting that the chiropractor said the physiotherapist should've been able to work this out himself when it became apparent that treating the knee was not working, and had the physio done their job properly, he would have been able to alleviate the pain and I would probably have not ended up needing to visit her. I was rather annoyed by this because it meant in all probability that I had been putting up with that pain unnecessarily for years

Most interesting.

Although I did not intend this thread to be championing chiropractic healing, I can see a thesis pointing to possibly scientific endorsement, of manipulation. The idea that nerves are getting pinched in various places in the spine, has a ring of truth about it. The fact that chiropractors are not the only ones who do manipulation adds some weight as well.

I am quite prepared to accept that physiotherapy may help in some cases, where some stretching and other exercises are used. What I am dubious about is the applying of pressure, causing considerable pain, to sore spots. This is what I have been subjected too. Has anyone heard of a theory explaining the mechanics of how this is supposed to help?

When science is applied to a problem, observations are made and measurements are taken, a thesis is born and evidence examined, to support or contradict. I wonder what's been done to validate physiotherapist treatment.

[Modified]

Originally Posted by Thor 2

Most interesting.

Although I did not intend this thread to be championing chiropractic healing, I can see a thesis pointing to possibly scientific endorsement, of manipulation. The idea that nerves are getting pinched in various places in the spine, has a ring of truth about it. The fact that chiropractors are not the only ones who do manipulation adds some weight as well.

I liken most manipulation to hitting an old CRT TV that was misbehaving. Sometimes it fixed it; sometimes it made it worse; sometimes it did nothing; rarely it killed the TV.

[Squeegee Beckenheim]

"Here is copious scientific evidence that chiropractic is dangerous woo"

*crickets*

"Here is a singular anecdote that agrees with your viewpoint"

"Ah, this has the ring of truth, and could be scientific endorsement"

Well, there's no arguing with the tenets of religion.

[arthwollipot]

I saw a chiropractor for years too. And he did produce some noticeable improvements in certain kinds of lower back pain that I was having. But I had to keep going back for monthly "adjustments" to maintain my "wellness". When I stopped doing that because **** that, I did not see any real disimprovement. Hence I conclude that I didn't need to have been doing that.

[rockinkt]

Physiotherapy has become the default position like Alcoholics Anonymous.
No great evidence that it works any better than any other program or system but still the easiest and safest referral option for physicians and other healthcare professionals.

[angrysoba]

About manipulation and chiropractors, Steven Novella says:

Quote:

Manipulative therapy

There is evidence to support the very narrow indication of spinal manipulation for the symptomatic management of acute uncomplicated lower back strain. The good news for chiropractors is that this is a very common condition and does not respond well to conventional management – actually all treatments: medical management, physical therapy, manipulation, and even just patient education, appear to be equally and quite modestly effective.

There is a body of clinical studies that are relevant to the question of manipulation for lower back strain. A review of this research was published in 1989 by the RAND corporation, an independent research group that put together a panel of both physicians and chiropractors to review the available research on manipulative therapy. They concluded that evidence from 22 studies supported the use of manipulative therapy for acute uncomplicated lower back pain (again – no real pinched nerves). It is important to understand, however, that they were referring to manipulative therapy, not chiropractic. In fact only 4 of the 22 studies mentioned included chiropractors. In the other studies the manipulative therapy was performed by physicians and physical therapists.

The RAND study went on to enumerate a long list of situations in which spinal manipulation should not be performed, including evidence of nerve root compression. Other contraindications include a greater than 6 month duration, X-ray or clinical evidence of malignancy, failure to respond to manipulation or a history of not responding to manipulation, among others. They also concluded that there was insufficient evidence to justify the use of manipulation for most forms of chronic lower back pain. The study in no way supported chiropractic subluxation theory or the scope of chiropractic practice. Nor did it make any comparison between manipulation and other forms of treatment for low back pain.

Because of the popular confusion of chiropractic with manipulative therapy, and the use of manipulation for symptomatic treatment vs the pseudoscientific treatment of subluxations and innate intelligence – some chiropractors were able to exploit this and other positive studies of manipulation to advertise that “chiropractic works” as a way of promoting chiropractic treatments that have nothing to do with manipulation for lower back pain.

Link

In other words, if you think manipulation in general, or chiropractics specifically is going to help your aches and pains, then good luck!

It's worth reading the whole two-part piece by Steven Novella.

For many people, I think that sound of popping and crackling makes them feel, "Well, this must be doing something for me!" and has a placebo effect. Of course, every time they go back it is easy to make the same popping sounds and pass that off as releasing stress or realigning your spine. It's pseudoscientific BS.

FWIU, if a chirpractor says he is worried about your posture and wants to "correct" it with manipulations, then absolutely run away as far as your misaligned legs will take you.

[EHocking]

Originally Posted by rockinkt

Physiotherapy has become the default position like Alcoholics Anonymous.
No great evidence that it works any better than any other program or system but still the easiest and safest referral option for physicians and other healthcare professionals.

What are the scientific/medical programs or systems that are equivalent to, an alternative to, a replacement for, or preferable to physiotherapy?

e.g., what rehabilitation would you recommend for post-shoulder surgery, for instance?

[Squeegee Beckenheim]

Originally Posted by rockinkt

Physiotherapy has become the default position like Alcoholics Anonymous.
No great evidence that it works any better than any other program or system but still the easiest and safest referral option for physicians and other healthcare professionals.

If you go to google scholar and search "physiotherapy" and "meta analysis" you'll find that meta analysis after meta analysis finds that there is good evidence that physiotherapy has significant benefits for recovery from a variety of ailments, at least in the short-term (i.e. measured in months as opposed to years).

[Modified]

Originally Posted by EHocking

What are the scientific/medical programs or systems that are equivalent to, an alternative to, a replacement for, or preferable to physiotherapy?

e.g., what rehabilitation would you recommend for post-shoulder surgery, for instance?

The same exercises without a physiotherapist in the room. I know a few people who quit recommended sessions because they realized they could do the same things themselves.

[bruto]

I've had reasonably good results from physical therapy, in each case by a place that concentrates on sports medicine. I do agree that, in many cases, you could do just as well by doing the exercises yourself, but it can help if you see a person who knows what those exercises are, and at what rate you should be doing them, or adding them, so as not to cause additional injury. It likely depends a lot on the skill of the people involved. The ones I've dealt with (especially a particular one) are pretty well trained to figure out just what is doing what, where and why.

I think there are definitely degrees of effectiveness and differences in practitioners, but I found it pretty helpful after shoulder surgery, a subsequent serious accident, and recently after a slipped disk. In the latter case, which I'm still getting treatment, the problem seems to be only partly one of spinal injury, but also of a slightly tilted posture, and that is part of what is being worked on.

It may be that chronic conditions don't respond very well, but if you've just broken your neck, I think it's not such a bad idea to have a good physical therapist to tell you not only what to do next, but when to stop. e.t.a. but I would also agree that once you have the exercises figured out, there's little reason to keep going if you have the self-discipline to continue on your own.

[EHocking]

Originally Posted by Modified

The same exercises without a physiotherapist in the room. I know a few people who quit recommended sessions because they realized they could do the same things themselves.

So (the rule of) the program or system that physiotherapists use are scientifically and medically sound? Which was my question to rockint- what is unsound about physiotherapy?

My physio did just as you describe, gave me handouts outlining exercises to continue after a couple of sessions with her.

[abaddon]

Sigh.

I comprehensively shattered an ankle. After the cast came off and the inserted metalwork settled in, physio returned my ankle to near normal function.

I still get a slight limp in really cold/damp weather, but it remains at near 100%. Do you really think that would be the case without physio? No chance.

[Modified]

Originally Posted by EHocking

So (the rule of) the program or system that physiotherapists use are scientifically and medically sound? Which was my question to rockint- what is unsound about physiotherapy?

I assume most of it is unproven, like much of medicine.

In the cases I'm thinking of, the exercises were for scar tissue management. There seems to be little evidence that scar tissue massage is useful in the long term, and most of the studies for scar massage and stretching seem to be specific to burn scars. I suppose it is just accepted as true that keeping a body part moving while it heals will reduce the chances of it being welded to another by scar tissue.

Quote:

My physio did just as you describe, gave me handouts outlining exercises to continue after a couple of sessions with her.

In my experience, that is usually what they do after the sessions covered by insurance run out, but not before.

[angrysoba]

Originally Posted by abaddon

Sigh.

I comprehensively shattered an ankle. After the cast came off and the inserted metalwork settled in, physio returned my ankle to near normal function.

I still get a slight limp in really cold/damp weather, but it remains at near 100%. Do you really think that would be the case without physio? No chance.

A shattered ankle you say? Well, sure, that’s what Big Pharma will have you believe; but have you considered that maybe your subluxations in your spine were out of whack?

[abaddon]

Originally Posted by angrysoba

A shattered ankle you say? Well, sure, that’s what Big Pharma will have you believe; but have you considered that maybe your subluxations in your spine were out of whack?

Crawling down my hall to open the door for the ambulance crew was a slight hint, perhaps.

[Darat]

Originally Posted by Modified

The same exercises without a physiotherapist in the room. I know a few people who quit recommended sessions because they realized they could do the same things themselves.

I've been seeing sadists since I was 13, apart from when special equipment was required the physios taught me exercises for me to do at home. I would say that's the case for most physio.

[EHocking]

Originally Posted by Modified

I assume most of it is unproven, like much of medicine.

?!
Really? I'd be intrigued to see the scientific studies that support that assertion.
But I guess not here as it would be OT.

Quote:

In the cases I'm thinking of, the exercises were for scar tissue management. There seems to be little evidence that scar tissue massage is useful in the long term, and most of the studies for scar massage and stretching seem to be specific to burn scars. I suppose it is just accepted as true that keeping a body part moving while it heals will reduce the chances of it being welded to another by scar tissue.

I'm not familiar enough with the phsysiology to comment.

Quote:

In my experience, that is usually what they do after the sessions covered by insurance run out, but not before.

I guess that depends on where you live and how that country's insurances work.

It has not been my experience, or the experience of family or friends with similar injuries or surgeries.

[Carrot Flower King]

Originally Posted by Darat

I've been seeing sadists since I was 13, apart from when special equipment was required the physios taught me exercises for me to do at home. I would say that's the case for most physio.

Quite: that's pretty standard practice in the UK. You are taught exercises so that you carry on doing them regularly between sessions.

[Modified]

Originally Posted by EHocking

?!
Really? I'd be intrigued to see the scientific studies that support that assertion.

Much of what's done in medicine is done just because it is obviously what is needed and it obviously works, and is too obvious to be studied. Sometimes though, those obvious things do get studied and turn out to be more harmful than helpful on average.

[Modified]

Originally Posted by Carrot Flower King

Quite: that's pretty standard practice in the UK. You are taught exercises so that you carry on doing them regularly between sessions.

Right, I expect the "You need exactly as many sessions as insurance will pay for" is mainly a US thing.

[Hellbound]

Originally Posted by Modified

Right, I expect the "You need exactly as many sessions as insurance will pay for" is mainly a US thing.

To be fair, the number of sessions set by insurance is usually the amount needed by most patients. The have actuarial departments to determine just this sort of thing.


Sent from my iPhone using Tapatalk

[Modified]

Originally Posted by Hellbound

To be fair, the number of sessions set by insurance is usually the amount needed by most patients. The have actuarial departments to determine just this sort of thing.

It's usually a very rough number based on limited information.

[bruto]

I think in some cases physical therapists would rather go on past the end of insurance coverage, but since they know you won't, they sort of have to go with the reality. Others, no doubt, are trying to maximize their income and could stop sooner. It's up to the patient to decide where to draw the line, I think.

Some of this is likely also a matter of what sort of patient you are. A surprisingly large percentage of people don't do the home exercises they're supposed to, and I presume the practitioners know this. If you're the kind of person who actually does all the exercises, then you're probably well off quitting the sessions sooner. Or you can decide to keep going for the cost of the copay and let the insurance company pay the bulk.

[Thor 2]

I've been trying to research the question, regarding the scientific basis of physiotherapy treatment, with little success. One gets told, almost like a mantra, that it is scientifically based but finding detail about the proof is illusive.

[Darat]

Originally Posted by Thor 2

I've been trying to research the question, regarding the scientific basis of physiotherapy treatment, with little success. One gets told, almost like a mantra, that it is scientifically based but finding detail about the proof is illusive.

If you think about it that’s because it encompasses so much. If you look up an individual treatment provided by physios you can often find papers.