Physiotherapy (1894-2020)


A once-proud profession that lost its way and uncritical accepted too many fads, pseudoscientific interventions, low-quality treatments, passive modalities, and alternative treatments, based upon only a scrap of evidence.

 “I have tried physiotherapy, and it did not help me!”

This is a typical comment from many people living with pain; they have been to 2-3 physiotherapists and have tried numerous interventions, but often only low-quality treatments and passive modalities.

It is disheartening to hear vulnerable and disabled people share their story, and realize that they did not get a single high-quality treatment. They got served up a platter of misinformation, told scary shit, and persuaded into outrageous amounts of useless low-quality treatments.

Low-quality (quick-fix) interventions and passive modalities (like manual therapy, ultrasound, shockwave, low-level laser, dry needling, and acupuncture) have been degrading and dumbing-down physiotherapy and pain management for many many years.

We don’t improve the quality of care by being “positive” all the time and being overly optimistic towards every type of new fad modality (or “tool”). Part of providing higher quality care is saying no to low-quality treatments.

Low-quality interventions and is almost always done with the wrong patient narrative (“fixing” the body), and the wrong mindset (operator not interactor), and for the wrong reason (practitioner-centered and not patient-centered), and only supported by an outdated model (biomedical). An intervention should be something that you do with a patient, not something you do “to” a patient, like all the above passive modalities.

If the physiotherapy profession has the intention to be still a highly regarded provider, we must initiate profound change. The current outdated clinical narrative is unacceptable; urgent change is necessary for our survival. We need this change to secure the range of benefits we and the profession have set as our goal, like direct referrals.

Let’s focus our energy and spend our valuable time on something that makes much more sense. Modern physiotherapy should be informed by both qualitative and quantitative research, including research topics like: Pain experience (qualitative), shared decision making, therapeutic alliance, patient empowerment, patient communication, patient-centered practice, risk factors, hypertrophy, movement variability, and clinical decision making, to name a few. This, in addition to research fields like pain science, rehabilitation science, exercise science, behavioral science, and many more.

We need to reimagine and reconceptualize the pragmatic treatment of people with pain. Research can encourage and facilitate clinical change, but research does not help people; the skillful clinical reasoning of a clinician does.  Only we as clinicians can implement this change, and every single person we take under our care deserves this change.

Thanks to Peter O’Sullivan and Max Zusman for inspiration to write this article.