Guest post by Lucie Crouch. Lucie is a freelance journo by day, and shoe lover and sceptic by night. You can follow her on Twitter @LadyLucieCrouch
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Physiotherapy is something that most people just assume is going to work because it’s recommended by your GP and you have to have a degree (technically) to practice it. What a lot of people don’t know is that it’s just as full of charlatans who don’t necessarily have the knowledge or experience to help you.
I slipped a disk in my back this summer, and after repeatedly visiting my doctor, desperately in need of help my doctor referred me to a physiotherapist. Two in fact. The first lady I went to charged me through the nose, but in fairness to her, she really helped me and sorted a lot of my back pain out. The second girl most certainly did not.
Don’t get me wrong, I’m not poo-pooing the whole industry, all I’m saying is that you need to choose your therapist really carefully because a lot of what they recommend is not only ridiculous but really doesn’t have an effect.
My first therapist was really well trained and could tell just from the way I sat and walked what and where the problem was. She basically told me that she could massage my back as much as I wanted, but the healing would come from building the strength back up in the muscles in my back again. It took a couple of months but I was off pain killers completely after she had treated me, and she recommended a lower back support which would give me a bit of extra help on the way. She explained that my back took a lot of strain, but as long as I built up the muscle strength with good, focussed exercise I’d be fine. Happy days.
So returning to college I thought I’d be fine, until I fell over in a pair of heels on a night out. The disk in my back twanged out, and I knew I would need a bit of help again.
So, being 500 kilometres away from the last therapist I decided to branch out and came across a young lady recommended by the local health authority. To put it simply, she really didn’t know what she was doing. When you slip a disk, it’s basically dislocating your back, it’s seriously painful and you usually can’t walk, sleep or do anything for days. And you’ll be on some serious opiate-based pain killers. The first session was basically her taking notes of my condition, and softly touching my back here and my left leg there. I’m personally not a fan of the soft approach, I’d rather not beat about the bush and just get the problem fixed. So going to my second session, I expected a little bit more, and how wrong I was. Basically, what this charlatan told me to do, was raise my left leg, three inches in the air, move it left and right, then set it down again. I was told to do this ten times a day (if I was up to it?!) and then come back after two weeks and see how I felt.
No my sceptical bone was kicking in right now. This sort of problem needs serious help and even though I wasn’t trained I knew that. So honestly I tried doing the exercises without sending me into a complete rage, then went back to her after two weeks and told her (animatedly) that there was no difference she had another look at my back and said “Oh I’m so sorry I think I’ve diagnosed you wrongly, you’ve been exercising the wrong leg”.
I couldn’t believe what I was hearing. How could she have gotten the wrong leg? This person supposedly has a medical degree and made such an error. Also I told her I was pretty sure I was aware of the pain being in my left leg, the diagnosed leg, and I’d told her it was that leg, so how could she have gotten it wrong? She sort of faffed about and booked me in for another appointment, which unsurprisingly I turned down.
I’d still been using my back support belt which had gotten me through pretty well, and I’d been doing my exercises the previous therapist had recommended.
I re-visited my previous therapist and she was rightly appalled by this, and couldn’t believe the amateur hadn’t harmed me further.
I do think physiotherapy can help people a lot, but you need to be really sure you have the right therapist for you so you don’t waste time or do more damage.
Hi I’m Heather! Please email me, I have a question about your blog! LifesABanquet1(at)gmail.com
“I do think physiotherapy can help people a lot, but you need to be really sure you have the right therapist for you so you don’t waste time or do more damage.”
– same goes for doctors, in fact any practitioner of any sort. Always do your homework, particularly after the first visit, it is quite possible to learn more about your ailments than they know, and test their knowledge by asking strategic questions.
Right, so let’s try a little test for the skeptical among us, as opposed to the “oh this must be bullshit”ers:
(1) Sit up straight on the edge of your chair.
(2) Place a hand on your back and find your coccyx, then move up your spine 4-5 vertebrae. Now move your hand outwards about 1 inch, just to the outside of the erector spinae muscles (the big vertical ones).
(3) Straighten both legs in front of you (heels on the floor).
(4) Lift one leg up three inches, move left, move right, and back down onto the floor.
Did you feel anything? That bulging is your traverse spinal muscles working (http://en.wikipedia.org/wiki/Transversospinales_muscles). They’re part of the group colloquially known as “core muscles” and are responsible for keeping your vertebrae appropriately oriented.
When you suffer a spinal disc herniation (which is something pretty damn serious – it can cause permanent nerve damage and paralysis!) (http://en.wikipedia.org/wiki/Spinal_disc_herniation) the function of the transversospinales is often affected. They may overwork and spasm in an attempt to compensate, or they may weaken from lack of use. When these muscles are impeded you’re going to get back pain (somewhere – could be lumbar, thorasic, neck, who knows).
So you have a couple of directions for treatment:
(a) Painkillers, rest, and hope it comes right.
(b) Surgery.
(c) Painkillers, massage, and rebuild muscular strength.
(c)(i) Approach 1: spend time on diagnosis, establish symptoms and severity, begin cautious targeted exercises that are calculated to avoid worsening the problem.
(c)(ii) Approach 2: loosen up the muscles and work ‘em to rebuild strength.
So your physio got the wrong leg? That’s not entirely surprising. The specificity of leg pain is low with spinal injuries. The physio is making a calculated guess that greater pain in one leg plus greater pain one one side of your back equals a high likelihood that its the transverse muscle on a particular side that needs work.
We also have a metric crapload of science on muscle building that tells us how many times to contract, at what frequency and load, rest periods and repetition schedule lead to the best muscle building for a particular purpose (strength, endurance, speed). For injured muscles the science supports to 8-12 repetitions at 24-hour intervals, concentric or eccentric exercise depending on the injury. You later move to 3-6 sets of 3-6 repetitions at 48-hour intervals to build strength.
You other physio was appalled? No surprises there either. My doctor is (rightly) appalled by other GPs prescribing antibiotics for viral infections, but 70% of GPs do it anyway. A chiropractor was appalled that a physio intended to do spinal manipulation on me without having an X-ray to verify that there was no nerve compression. I am frequently appalled by other domain experts in my field of expertise who take a different – but admittedly valid according to our formal training – approach to certain problems.
> I do think physiotherapy can help people a lot, but you need to be really sure you have the right therapist for you so you don’t waste time or do more damage.
The conclusion is correct. Rehabilitation is a slow process, and you need to work with someone whose approach is compatible with your expectations. That doesn’t make one of the physios a charlatan.
Well argued, great conclusion. The original article could have been summarised to “I went to two physios – one worked and one didn’t”. Based on the sample size (n=1 of each) we can’t scientifically (or ‘skeptically’) say anything more. Therefore the title of “…what works, what doesn’t, and what to avoid” is expansive and misleading. Being a proper skeptic means that you have to restrict your conclusions to deductions based on the genuine facts. And facts can be camoflaged, as Trevor highlighted. Calling oneself ‘skeptical’ or ‘scientific’ does not give us the right to condemn something in the name of avoiding having the wool pulled over our eyes. Science and scientific reasoning is very powerful, but also (and as I scientist I say this based on some experience) terribly slow and plodding and intrinsically dappled with doubt (we call it error or variation).
You guys are completely right, I think this is a really bad article and I would delete it if it wasn’t for your great comments. Thank you.
I will be far more careful before accepting “guest” posts in the future.
Interesting..
I am currently seeing an NHS rehab physiotherapist who seems resoundingly sensible. He seems evidence-based and practical, but since being ill I have seen ads for all kinds.. Aimed often at frustrated and vulnerable groups..
This post will make me even more cautious!