Who's Actually Keeping Physios in Check?

If I think about my own appointments with physiotherapists as a patient recently, I’ve been told I need an MRI and I’ve been told I don’t. I’ve been told I need an injection, and the next one said I don’t. One says I need eight treatments, one says a couple and I’ll be fine. One says it’s my hamstring, the other says it’s my glutes. Same leg and still the same old me. And I think any profession, especially one that’s supposed to be science-based, should have some level of consistency. As a patient it’s actually quite worrying, and certainly not reassuring, to be handed polar opposite views by people with the same letters after their name. If I called three plumbers out to the same boiler and got three completely different diagnoses and three completely different bills, I’d assume at least two of them were having me on. I’m not sure why physio should be any different. **Nobody’s keeping an eye on them** It seems to me, as a patient, that no one’s really keeping physiotherapists in check, whether that’s in the NHS or privately. You need only look around at every other physiotherapy website offering cupping, or some new longevity treatment, or a new machine that promises to cure everything from back pain to ankle pain. You’ve got physiotherapists using electromagnetic waves with little or no evidence. You’ve got shockwave being offered for pretty much anything. And on that note, it also seems that physios are stepping outside what they’re individually competent in, and moving into areas they’re simply not qualified to move into. Nobody appears to be stopping them. **So how am I supposed to choose one?** How do I choose a good physio? It’s not because they have a degree. It’s not because they have an HCPC number, or they’re a CSP member, or a Physio First member. It’s not because they own a clinic, and it’s not because they’re a Band 5 or a Band 6. None of those things told me which of my physios was right about my hamstring. So on what basis can I choose one, and how do I know I’m going to get good treatment? Which brings me to the question of who should be overseeing what physios do and don’t do. I had a look through the HCPC’s hearings involving physios, and there are obviously (and quite rightly) cases to do with sexual impropriety and legalistic issues, and some to do with competence, but I couldn’t find one about cupping, or a laser, or telling someone they need ten treatments for their back when the physio down the road says it’s their hamstring. If a physio says you need cupping to help with your back pain, maybe they’re right. But if they’re not, who says so? Is there any link between the Advertising Standards Agency and any organisation within the world of physio? Because the advertising rules already exist, and from the websites I’ve been reading, nobody in physio seems to be using them. Is ongoing training really taking place, and if it is, is it effective? If it’s happening, I can’t see that it’s working. And here’s the real problem. The HCPC has failed. The CSP has failed. Physio First has failed. What do I mean by failed? Well, as far as I can see they are the main bodies in the industry; the ones with the widest reach. The HCPC is the regulator, so I’d expect it to be the one saying no to the vibrating massage balls and the cupping, and it isn’t. The CSP is the professional body, so I’d expect it to be the one making sure its members can read a research paper past the abstract, and it isn’t. Physio First represents private practice, so I’d expect it to play some role in advising clinics on taking the mystical stuff off their websites. **It should be a science** I’ve seen someone describe physiotherapy as an art form as if it’s like painting, where two very different things can be good at the same time and three things can all be true. But physiotherapy isn’t an art. It’s a science, or at least it should be, and I don’t think it is a science any longer, because science is about evidence - the best evidence we have available at this moment in time - and that’s not what I’m seeing. We’ve got older physiotherapists leaning completely on what they know, what they’ve seen, and anecdotal evidence. During my research I’ve seen physios broadly incapable of reading PubMed research beyond a headline and a conclusion. The same older physios are busy saying new graduates simply aren’t qualified to be anywhere near patients, and I fear that might apply to quite a number of them too. After all, we can’t even get physios to agree on whether manual therapy is a good thing or not. I’ve heard people say innovation is important, that there’s not always science behind innovative ideas, that you have to try things and have an open mind. As Carl Sagan is supposed to have said, having an open mind is a good thing, but not when it’s so open that your brain falls out. **A new toy every fortnight** One physio I’ve used seems to get a new piece of equipment every two weeks and sends out an email telling us how wonderful it is. Some measurement device or some healing device, something you jump on, something that rumbles and vibrates, new foam rollers, fancy boots you put on your legs, a handheld vibrator that buzzes you in some way, or a futuristic laser that looks like it belongs in Battlestar Galactica - all curing one ailment or another. Whilst the physio down the road says they don’t need any of those things and spends their time going through what’s actually wrong with me and what progress might look like. When there’s such vastly different advice out there, who do we believe? **Is six a magic number?** When it comes to the private physiotherapy world, from what I can see the overriding aim now is to make money and not to help patients. Every area is commercialised. I asked Google for the top ten clinics in my area, got a list and went to their websites. Four out of those ten sold packages of physiotherapy that I could buy there and then by clicking ‘book now’. Unless physiotherapists have somehow developed an incredible level of perception, or the ability to read minds, I don’t suppose they’d know whether I needed six sessions or ten without seeing me. So I had a look around at as many clinic websites as I could stand selling packages of three, six, ten and twenty sessions, and the overwhelming majority offer a package of six. So I wondered, is six a magic number? Is there some physiological reason that six is the number of sessions you need? Strangely, these clinics, for whom six seemed to be the default, all offered different appointment lengths. Some were 30 minutes, some 45, some 60. One offered 90, which I suppose means two of theirs equals six of someone else’s…or that nobody’s measuring anything. It made me wonder why one clinic needed a 60-minute initial assessment to figure out what was wrong with me, another needed 45, and another needed just 30. Are they twice as quick at diagnosing, or just half as thorough? **Physiotherapy you can trust, apparently** Then there are the websites. One clinic’s homepage tells me its physiotherapy is evidence-based and I can trust it. A few clicks later I’m reading about needles rebalancing something or other, the body’s natural healing being unlocked, and a happy chemical being released that will leave me feeling better in myself. And of course the old favourite, that it’s been used for centuries, which is great as historical context but isn’t exactly evidence that something works. Many things have been used for centuries. Tobacco smoke enemas, for one. Another site tells me its shockwave machine regenerates tissue and mends what’s damaged, and that it works for tendons and, in a phrase doing a lot of heavy lifting, various other muscle problems. And then there’s the clinic that’s obviously spent some money on a new toy. According to the website, this one speeds up healing, tells you when you’re ready to go back to sport and, my favourite, lets you get there without risking another injury along the way. What is this magical product? A measuring device. It … This is a public episode. 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