They arrive at my door via consultants, through recommendations and sometimes just by chance. Treating these complex chronic cases is the absolute highlight of my job. Short term it is exhausting, I must admit. Motivating people who have become understandably jaded by medical people and their own bodies and suffer horribly with pain is no small task, However, with determination, energy and a dedication to thorough in clinical analysis, watching a patient transform into a highly functioning, happy human being is a huge privilege and a truly wonderful experience.
These positive outcomes are supported by validated clinical outcome measures which direct treatment, measure improvement and are essential on keeping patients on track over the long treatment period. I follow up all my patients and I never give up on them.
So, I hope you understand why, when I hear the phrase 'physiotherapy failed,' I get angry.
This phrase does no justice to those in pain, in particular those that have had their pain for six months or more when they slip into a category called chronic pain. For a multitude of reasons the media and the medical world seem to think that chronic pain is not treatable with physiotherapy. As a result they end up having unnecessary surgery and/or injections, taking endless medication, wasting money on therapies that do not work, withdrawing from their family and social lives, and being unable to work.
So please, if you are one of those who have had pain for a long time and are reading this... CHRONIC PAIN IS TREATABLE AND YOU CAN GET BETTER*. I SEE IT EVERY DAY AND THE RESEARCH BACKS UP THIS OPINION. YOU JUST NEED THE RIGHT TREATMENT. So please, go and get a second opinion or even a third opinion from an experienced physiotherapist if you are not getting better.
If you are a GP or consultant reading this please don't just ask 'have you had physio' but inquire more closely as to what the physio entailed. Based on clinical research and my experience here are the things that indicate whether they have had thorough physio:
1) Course of physiotherapy that lasts 3- 18 months.
2) One to one face to face sessions with the same physiotherapist on a weekly basis for about six weeks then fortnightly for another couple of months then reducing down to every 4-6 weeks. The sessions need to be a minimum of 30 minutes, ideally one hour. There should be NO follow up 'check ups' beyond this. Physiotherapy for chronic pain should never be ongoing.
3) Advice on pacing, incremental build ups, how to manage and reduce flare ups. Use of an activity diary NOT a pain diary.
4) A structured programme of whole body general exercise (ideally with a cardiovascular element) like walking, swimming, whole body exercises. The key here is the STRUCTURED PROGRAMME.
5) Outcome measures based on function not pain for example the PSFS or 'Patient Specific Functional Scale'
6) The patient should be able to demonstrate exercises to you that are obviously related to the activities they are targeting, in other words 'functional exercises.' For example mini squats, sit-stand, step ups and loading these positions or movements with weights, bands etc.
7) Full assessment of all the painful movements and modification of the way they are doing these movements. For example correction of seating position, work station set up, walking pattern, lifting and carrying technique,
8) Exercises given should be fully demonstrated and practiced with the physiotherapist with the use of mirrors and/or tactile feedback. Handing someone a sheet of exercises is NOT physiotherapy.
9) Hands on physiotherapy and/or acupuncture can be essential to enable the patient to move and load their musculoskeletal system which is what will reduce their pain. In other words acupuncture and hands on physiotherapy are very valuable in reducing pain short term so that the patient can exercise and recover long term.
So now for the elephant in the room. Who is going to pay for this? Unfortunately, apart from sparsely scattered exceptional pockets of money, the NHS as it stands will not do this. Even many insurance companies won't. So ultimately it comes down to whether the person has something in the vicinity of £1000 to spend on getting rid of their pain.
The injustice of this is glaringly obvious and so is the lack of logic that sees a life time of disability allowance - tens, or perhaps even hundreds of thousands of pounds - being spent where £1000-2000 of physiotherapy could have prevented the expenditure**.
One thing I hate almost as much as the phrase 'failed physio' is health provision based purely on economics rather than ethics. On a moral level, if people are in pain and can be taken out of their suffering with the right treatment, how can we justify not giving them this treatment?
This is a big topic, I plan to refine it and I would be grateful for your lead in the form of comments.
*Of course there are cases where function does not improve in response to treatment but in my 15 years of clinical experience I have never experienced this.
** This is clearly linked to the fact that those accountable for the NHS pot of money are completely different to those accountable for the disability benefits pot of money. The solution is therefore politically very lofty!