Physio Will Eat Itself

PWEI physio2

I suppose this is about change. We might be doing ourselves irreparable damage you know, as a profession. I just read Dave Nicholls’s Should we give up physiotherapy? , and I just saw Kettlebell Physio Neil Meigh’s Facebookey Livey thingy, and I’ve been concerned about the de-commissioned physiotherapy services in Nottingham  and been interested in the proliferation of “myth busting” initiatives (all good stuff BTW, except for the de-commisioning) and wondered about a tone and trend being witnessed within the profession, perhaps best exemplified by posts like this:

Meakins LBP

Now before Meakins gets all “oi you little barrrstid, that’s right proper fackin’ science that is you old spanker” on me, I’m not saying this is bad/wrong/evil/or anything – in fact the opposite. It’s lovely. Meakins’ post is, as always, a provocative and grounded signal to make all of us sit-up and think a bit more about what we are doing and who we are. There are two dimensions to this post, first something about treatment of LBP (but it could be any are of practice), and second something about the quality, or state, of practice. Both essential areas to continually be reflecting upon in the light of new evidence.

Dave Nicholl’s blog asks us a critical question related to Sir Meakin’s first point: “if it were in the best interests of patients or the healthcare system as a whole, for us to disestablish physiotherapists, would we do it?”

Kettlebell Neil talks about not just the quality of practice, but also the extent of practice – wondering if we are spreading ourselves too thinly in some sort of desperate professional attempt to shift our allegiances and pretend to be things we are not.

These two points are of course related. If the evidence starts to question the utility of what we do at the moment, does it not make sense to become involved in other areas? The move from multi-modal, structure-based interventions for LBP, for example, might be taken as we see more evidence in favour of simple exercise based interventions. Or indeed no intervention at all.

So what is the issue with all this?

[OK, USUAL DISCLAIMER: I am of course wholeheartedly in favour of implementing the best evidence to ensure the best outcomes for people we engage with (what constitutes ‘best evidence’ is, however, a discussion for another day), blah, blah, blah. So before you try and use the “you don’t like change or science” argument, au contraire mon ami. In fact, during a recent office clear out, I happened upon this letter I sent to Frontline in 1999 advocating for change and science (and referring to Bob Dylan):

Frontline letter 1999 3

So there. Get over it].

The issue is, I think, one of professional identity, and what this means for the people we serve. The increasingly active dialogues which happen within the profession (perhaps the SoMe Echo Chamber is the best example, although these dialogues do occur elsewhere) are forever encouraging us to think, challenge our own beliefs, reflect, and progress. And quite rightly so. But whilst this is happening, there is an emerging phenomenon which seems to be getting ignored – how do we look from the outside? I wonder if anyone outside the profession knows who we are or what we do. In fact, I wonder if many from within know these things.  What is our identity? What is our USP? Who even are we?

Here’s one part of the problem. Our (possibly ever-so-slightly overly) enthusiastic attitudes to “new evidence”, which soon turn into vitriol:

“. . . you are such a loser for still doing foam-massage-mobilisation-needle-specific-electro-release techniques when this n=17 uncontrolled trial in Anals of a Physiotherapist’s P-value says it may or may not be better than tele-instructed stair-walking whilst reading a pamphlet about pain and pretending not to be frightened and I stopped doing what you’re doing like yesterday and now I’m better than you because I watched a well-produced slightly humorous video of a popular and charismatic physio god probably from Australia or America or somewhere like that with 11,000 Twitter followers who doesn’t do any grade III+ mobilisations anymore but uses metaphors instead and who I think represents the very best of science although I haven’t actually read it myself but he/she’s got a tan and a nice smile and is from abroad so it must be true and anyway I’ve read a pop-sci/psych/phil book so I know what a fallacy is and you do all of them and now I actually work as a Band 17b Advanced-Extended-Diagnostic-Rehab-Strengthener-Specialist-Wish-I’d-Been-a-Doctor-Consultant and I can do injections and prescribe Haliborange and do advanced metaphorical squats and minor surgery on gerbils so there you creepy practice-based-on-your-own-experience bastard fuckwit of a no-hoper.” (Author’s personal communication)

In goes without saying that both parties here are right and wrong in roughly equal measures. However, this vitriol soon turns into grand claims about what we should or shouldn’t be doing as a profession, and whilst all this is happening our public and our employers and our commissioners peek cautiously through the gap in the door and think “who the twattin’ ‘ell are this bunch of jokers?”.

Of course evidence and debate and progression are critical to the functioning of a profession. But this should be done with not only an understanding of the data, but also with a meaningful understanding of the sociocultural context in which such data are intended to be used. Humans and societies do not change quickly, even in the presence of over-whelming evidence that they should. Whilst we try and initiate rapid change in what we do, we risk alienating those we serve. If people are unsure who we are, they won’t sit around with their pain and their money and their contracts waiting for us to come to a consensus on whether we should do a squat with or without our bellies pulled in. No, they will seek the care and services of those they recognise and have confidence in. As they drift away, they leave us bickering and squabbling between ourselves, slavering with excitement at a few more Facebook likes, eating ourselves until we are no more.

Then that’s it. The end. Finito.

Be careful what you wish for peeps. Stay focused. Bridges not walls eh.

For a more considered and erudite argument related to this matter, I have recently had the joyous experience of writing a chapter with the incredible Fiona Moffatt for the remarkable Dave Nicholls’ astonishing CPN’s startling forthcoming anthology on Physiotherapy. Watch that space. But while you’re waiting.

[Banner logo adapted from © Pop Will Eat Itself (


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21 responses to “Physio Will Eat Itself

  1. corephysio1

    Reblogged this on .

  2. 2nd year Physio

    I am currently a year 2 Physio student. I began reading comments on Twitter from various physios with the aim to keep up to date and remain current in evidence based medicine. I have increasingly read various comments from certain physios generally arguing and slinging insults at each other’s practice.
    I am still very much a “beginner” and I am very aware of this. However, a huge amount of mixed messages, insecurity and confusion about what we do/ are meant to do/ are not meant to do/ who even are we anymore/ where is this profession going, is rife.
    Change and constant development is important, but I think how these changes and developments are handled and implemented is also highly important.
    I went into this profession hoping to help people and treat them in the most effective way possible, open to constant learning/ development. When reading through the various twittersphere comments and arguments/ insults between professionals, yes professionals, I begin to wonder what I’ve signed up for?

    • Dear 2nd Year Physio, you came into this with all the right hopes. Keep them, nurture them, realise them. Keep reminding yourself that YOU are the future. The twittershpere is a tiny part of a huge domain. Take it for what it is. Learn from it, and ignore the rest. Harness its power but don’t become a slave to it. Enjoy your career.

  3. Chris Barnett

    Poppies Fan ! Are we as a profession at Def Con 1?

  4. Thank you. I typically avoid posting on certain Physio discussion groups because I’m not up for the bullying that ensues. Your humorous take on such posts resonates with me. Marj

  5. Thank you, Roger, for a thought-provoking article. I see this as a call to arms.

    Increasingly over the last 2 years, I have become reluctant to look at my facebook/twitter feeds. The authors are invariably ferocious about their particular views. Their opinions are so strong that I am left feeling vulnerable, their statements having a near visceral effect on me.I have been tempted, but have avoided, to remove myself from these social media platforms. I do not do so because invariably they contain gems, points of interest or academic excellence. But oh the noise. It’s so noisy now. My head hurts. So much of this information is being shouted at me. I am reminded of the Dire Straits line, ” Two of them say they’re Jesus, one of them must be wrong”.

    I have been in Practice for 30 years. I started with a formal osteopathic training. I spent 15 years working alongside, and learning from, you and many other lecturers at the University of Nottingham. I incorporated many new skills. The dry needling course that I attended 10 years ago added to my repertoire. I now work alongside an excellent physio/pilates teacher and we continue to combine our skill sets. I listened to Mike Stewart’s excellent lectures about the use of language and metaphors. I don’t use it with many patients, but when I think it is relevant it is invaluable. I now write their actual words and at various points along the patient journey, I return to their themes. There are of course other examples. My point is that I assimilate all of these new practices and views. I reflect on their merits. Likewise, there are techniques/modalities that I no longer use due to evidence and/or my perceived lack of efficacy. I am a human magpie!

    I am no different to the vast majority of therapists who are changing their practice all the time. We should not denigrate how we used to practice in the past. We were all trying to do our very best for our patients with the available information that we had at that time. This is the true essence of reflective practice.

    Working at the coalface is tough. We need a large toolbox. We hope and try to take out the correct tools at the correct time. Looking at Roger’s article from Frontline he mentions the art of practice. This, to me, is of paramount importance. It is an art. The game that we are in will never be able to be condensed into just numbers….well perhaps N=1!

    In summary. Please, will those that speak out on these forums have greater respect for each other. Try not to tell your ‘listeners’ that everything they did is/was wrong. Instead, inform us so that we can become better practitioners if we keep our minds open to different viewpoints.

    Please don’t preach.

    Please don’t shout.

    I have a headache.


    • Kathryn

      Thanks Mark for your comments – I couldn’t agree more. I’d love for all the angry self righteous folk on Twitter to sometimes post a success or two – a humbling story where something sparked in the patient, a therapeutic relationship was formed, confidence was built in patient and therapist, science, experience, empathy and intuition used in equal measure, and on reflection a lesson or two learned to share with colleagues for a brighter future ahead. Stop all this grim and grimy navel gazing and get on with using their considerable skills to move onwards and upwards!

  6. Martin van Hoppe

    Many thanks for this blog, I so agree. And I feel I’m in a similar position as bonyman: practising for over 30 years. Some of the techniques I use are getting ridiculed by fellow physios albeit with a bit of humour and wit. Problem is that these techniques still seem to able to help people, a lot sometimes. Don’t get me wrong I read a lot, go to courses, follow trends and evidence. But I’ve seen in my years as a physio that evidence today can be seen as foolish tomorrow. I think we have to be careful that we don’t we “evidence” ourselves out of skills. For instance I’ve seen that in Ireland, where I work and live, manual techniques like massage and mobilisations are becoming less used by physios, chiropractors and others are becoming dominant. Now it might be unfashionable to use massage but therapies that have been around for centuries, like massage and acupuncture, have earned their merit, I think. Discussion is very valuable but to ridicule and dismiss can damage our profession.
    Don’t preach
    Don’t shout 😶. So right.

  7. jerry

    Cheers Roger as always insightful, thoughtful and a HUGE value addition to this discussion

    Interesting the comments above…

    I am at the point after 25yrs in Practice where I am just begging to tap the research regarding expectations, Therapeutic Alliance and Equipoise ( I had never heard that word prior to 2016!

    The COMPLEXITY of the PATIENT is undervalued in Healthcare and even more so is the complexity of the PERSON who is the Provider..

    The RESEARCH APPEARS to be pointing to the above factors to be the GREATEST correlation with anything WE do…YET most DONT (want?) learn about this… Even the “Pain Science” neglects the provider

    as the COMPLEXITY of the people becomes more real we will be faced with realizations not about treatments yet ourselves…


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  9. Thank you for the voice of reason! It is part amusing, part worrisome to take part of the usually overly enthusiastic and, as often is the case with people operating with a small amount of information and a narrow scope, righteous, to the point of being contemptuous, claims of (often young) physical therapists proclaiming this that and the other approach obsolete. While an evidence-based approach is an invaluable tool to say the least, it can also be a dangerous god to worship blindly and indiscriminately.

  10. St. John Smythe

    Can I ask how I become a band 17b? I’ve done a weekend course in Gerbil ENT surgery, but I don’t feel like I’m being recognised for my special skills where I am now.

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  15. Jonathan Picken

    Do you think it’s a case of ‘the more we know, the less we know?’ Absolute opinions are, in my opinion, usually down to ignorance. Maybe it’s the lack of good quality research in many areas that we, as a profession, are involved in that leave it open to interpretation and therefore differing opinions…

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