Let me start off by stating that I have no financial stake in the success of physiotherapy as a profession.
Last week, a patient came in with uncomplicated mechanical back pain of one week’s duration, with no red flags, and asked about seeing someone for “therapy”. I’m going to share with you exactly what I told her.
When I refer a patient to a specialist of any kind, I am asking their help with a very specific question. When that issue is resolved or stabilized, the patient’s care is returned back to me. This is the basic model of primary care that works well, given our skill sets. Everyone within the circle of care is evidence-based, which creates a sense of trust among the providers.
When I refer a patient to physiotherapy, for the most part I know exactly what my patients are getting into. They will focus on evidence-based strengthening, stretching, sport or activity-specific rehabilitation, and will give the patient home exercises to work on where possible. The patient is never asked for a pre-payment for a large block of treatments. The therapy proposed is for the minimum duration, and its continuation is largely determined by patient preference. If the treatment is not improving things as expected, there will often be communication with the primary care physician to ask for suggestions.
This is the physical therapy model that works for my patients, and improves patient outcomes while still being evidence-based. I know that when I send my patients to physiotherapy, they will not be sold supplements, herbal remedies, fad diets, or be encouraged to sign up for expensive “wellness programs”. I know that they will not be signed up for long-term commitments, detoxes, and full-body x-rays. I know that the physiotherapist will not encourage them to bring their whole family to them for regular “adjustments”. I know that the physiotherapist will not try to use physiotherapy to treat ear infections, asthma, and improve their immune system.
And most importantly, I know that the physiotherapist will not spend the majority of their visit disparaging vaccines, medications, and “Western Medicine”.
It’s fairly clear that I’m making not-so-subtle references to some of the practices of some chiropractors in North America. But before I get bombarded with hate mail, please hear me out.
For acute musculoskeletal injuries, there is fairly broad consensus that manual therapy does improve pain, whether it be from physiotherapy, massage therapy or chiropractic care. And patients are adamant about this. The therapy for the most part does work to decrease pain. But the means by which it improves pain is where the disagreement lies. It is not through adjustments of so-called subluxations, or by improving energy flow, or any other fanciful non-evidence-based explanation. Manual therapy improves pain largely through a neurophysiologic model that is achieved through any form of manual therapy, both through central and peripheral mechanisms. No magic, and no need for lifelong treatment for maintenance. Home stretching and strengthening programs for “maintenance” should be the standard after acute treatment.
I like to think I’m a fairly reasonable family physician. I am deeply passionate about nutrition and exercise, and discuss this with patients at almost every visit. I promote yoga, meditation, and mindfulness….not because they possess any magical powers above placebo, but because they get my patients to relax. I suggest free resources for all of these things wherever possible. It is my responsibility to ensure a patient’s treatment course is safe, effective, and cheap. I understand the financial motivation behind the messaging that physicians are evil and anything “holistic” is good, but it’s a false dichotomy and not rooted in any truth.
I know that many chiropractors do limit their practice to short-term musculoskeletal treatment and evidence-based health promotion, and I want to give them an opportunity to set themselves apart from the rest of the herd. Chirobase.org provides an excellent guide to some of the issues surrounding chiropractic care, and where there is and isn’t evidence to support it. They also provide these guidelines for what patients should ensure their chiropractor practices:
My practice is limited to the care of musculoskeletal problems. I may also counsel patients about lifestyle improvements and give practical science-based tips about the management of common ailments. My approach to back pain parallels the AHCPR Clinical Practice Guidelines that lie within the scope of chiropractic. For medical problems outside my scope, I refer patients to appropriate physicians.
I publicly endorse immunization, fluoridation, and other standard public health measures. I reject biotheistic notions that “subluxations” and/or “nerve interference” are the cause or underlying cause of disease. I do not make claims about curing earaches or any other diseases. I do not (a) use free screening examinations as a patient-recruiting tactic, (b) try get patients to sign contracts for lengthy treatment, (c) promote regular “preventive” adjustments,(d) use scare tactics, or (e) disparage scientific medical treatment. I do not routinely perform or order x-ray examinations because most patients do not need them. I do not utilize 14″ x 36″ full-spine x-ray examinations.
I do not offer or advocate the use of Biological Terrain Assessment, computerized “nutrient deficiency” testing, contact reflex analysis, contour analysis (also called moire contourography), cytotoxic testing, other improper allergy testing, blind spot mapping, electro interstitial scanning,electrodermal screening, Functional Intracellular Analysis (FIA), hair analysis, herbal crystallization analysis, iridology, leg-length testing (to check for “subluxations”), live blood cell analysis (also called nutritional blood analysis or Hemaview), testing with a Nervo-Scope, Nutrabalance, NUTRI-SPEC, pendulum divination, provoked testing for toxic metals, reflexology, saliva testing, spinal ultrasound testing to “measure progress,” surface electromyography (SEMG), thermography, testing with a Toftness device, weighing on a twin-scale device (Spinal Analysis Machine), or any other diagnostic procedure that is unsubstantiated and lacks a scientifically plausible rationale.
I do not utilize or promote acupuncture to “balance meridians” or treat disease. I do not use or advocate the use of Activator Methods, applied kinesiology, auriculotherapy, Bio Energetic Synchronization Technique (B.E.S.T.), chelation therapy, Chiropractic Biophysics® (CBP®), colonic irrigation, cranial or craniosacral therapy, laser acupuncture, magnetic or biomagnetic therapy, Neuro Emotional Technique (NET), Neural Organization Technique (NOT), NeuroCranial Restructuring (NCR), NeuroModulation technique (NMT), or any other treatment modality that is unsubstantiated and lacks a scientifically plausible rationale. I do not advertise or offer expensive courses of treatment with spinal decompression machines. I do not “prescribe” homeopathic products. I do not sell or promote the use of unproven dietary supplements or herbal products for the treatment of disease.
I invite any chiropractors to check out this page, and add their name to that directory if they agree with the above guidelines.
Currently, I refer to physiotherapists because I know what my patients are getting with them. Health care decisions should be based on evidence, not anecdotes of benefit.
I’ll close with this passage from Harriet Hall from Science-Based Medicine:
What if chiropractic had policed its own ranks, limited itself to providing only short-term treatment for certain types of musculoskeletal pain, worked hard to determine which manipulation techniques were most effective, abandoned techniques that it found ineffective, and denounced vaccine rejection, applied kinesiology, and other forms of quackery? Manipulation might have been more widely accepted as a therapeutic tool if it had not been so tainted by the company it kept. Chiropractors could have become “physical therapists for the back,” experts in manipulation that MDs could refer patients to with confidence. Chiropractic might have been integrated into the medical mainstream just like osteopathy and optometry, but it didn’t even try.