Thoughts after attending a multi-disciplinary professional development evening

Sarah and I attended a professional development seminar the other week, featuring talks from allied health and medical professionals. It got me thinking and I thought I’d share my take-aways from the evening as they touched on some really common issues that come up in the clinic that I think warrant more thought and discussion. 

The role of physiotherapy in musculoskeletal pain

One of the presenters was a sports exercise physician. These are doctors who have extra training in sports and musculoskeletal (MSK) problems.

I often feel a degree of anxiety when patients see a doctor for an MSK concern, as they are often referred immediately to a surgeon or for an injection with no further instruction (not always, just sometimes). They can also be given extreme advice (never lift overhead! Never lift more than 5kg! Etc). 

I can also feel a little anxious when people are referred for physio with no explanation as to what to expect, as I presume the majority of the population expects this means massage +/- dry needling +/- stretches +/- mild exercises with a theraband. 

The sports medicine physician put what I perceive physiotherapist’s role into a few succinct dot points that completely resonated with me:

- Education

- Load management

- Strength & conditioning 

I actually think offering these as the main interventions as a physiotherapist is hard - even though I believe they are the most high value - because they involve talking/ planning and not much ‘doing’. People often expect that something will be ‘done’ to them at the appointment. 

This is not to say I don’t practice manual therapy, or that I am against it, it is simply that I do not generally feel it is the most high value treatment that people can receive, though it is often perceived as such. These 3 things (in my opinion) are the main physiotherapy interventions that matter. Manual therapy can help reduce symptoms in the interim. However I have often found that it distracts from these main points. I find when manual therapy is performed additionally to these management strategies, if a patient returns a few weeks later and is no better (as you advised would be the case, as the condition has a natural history of weeks to months) they perceive the entire treatment as ineffective, because the manual therapy had no real impact. It is often at this point a patient will seek surgical advice, citing physiotherapy didn’t work; however often in these cases in my opinion the most powerful interventions haven’t actually been given a fair go. 

Without the manual therapy, there is less distraction from these (kinda boring, and often hard to sell as an intervention) things being the main management strategies. 

It was really reassuring to hear a sports doc talk about these things in a way that showed me that the medical profession can and physiotherapists actually support each other really well and can be a great team for a patient, when the roles of each are properly understood.

Something we do at FKB Physio is provide our patients with a written summary after their initial appointment with the decisions we have come to together around load management & a clear explanation of what to expect for their recovery, which I continue to believe is essential and really important. Also important is the idea that we come up with a plan together - it is no use telling a patient to stop doing a movement all together that they need to be doing in order to continue to work, or look after their family; coming up with ways to reduce load that is actually actionable for that person is crucial. 

The role of cortisone injections in tendinopathy 

The sports medicine physician also discussed cortisone and PRP injections. It was reassuring to hear a person who provides these interventions be honest about their role as part of a whole picture, rather than a treatment in themselves. 

It is all too common for a patient to be diagnosed with bursitis (commonly shoulder or outer/lateral hip), be given a cortisone injection and sent on their way. I always try to advise my patients that it is rare for bursitis to exist independently (to my knowledge just 2% of the time in the hip, for example) and more commonly for it to exist alongside tendinopathy. Tendinopathy is a condition involving inadequate tendon healing in response to load. Bursitis is largely inflammatory. As an anti-inflammatory modality, cortisone may have a positive effect on an inflamed bursa, but will not have any role in treating an unhealthy tendon. 

I have often felt that cortisone could be useful in people whose pain level is completely intolerable/unbearable (e.g. affecting sleep), to at least provide some pain relief, but not indicated for everyone, and not a treatment in itself. The sports medicine physician essentially confirmed this bias of mine, and made it clear that with his patients, he outlines cortisone as a ‘cover-up’ that allows them to function, but that they need to remember there is a tendon problem that continues underneath this that is likely to cause symptoms again once the cortisone wears off.

Honestly, this simple explanation is missing in the majority of patients I have seen who have been prescribed a cortisone injection and I think it’s so important as so often cortisone is seen as a ‘fix’. Bear in mind that every diagnosis and pathology is different, and I am exclusively talking about tendinopathy here.

I find in bursitis/tendinopathy conditions in particular people are often diagnosed exclusively as having bursitis and are prescribed a cortisone injection in isolation which, as the sports doc mentioned, does nothing to address the tendon itself. 

Load management (reducing load to allow recovery then gradually adding it again) + strength and conditioning (around the affected area and gradually on the muscles attaching to the tendon) + education (advise that often these conditions can have LONG healing times & that is normal).  

The role of early loading in bone healing

Finally I was also interested in the occupational therapist’s talk about early loading for bone healing. A phrase she repeated was that early, controlled stress can help a bone to heal faster. That is, instead of completely immobilising a bone (e.g. in a cast for a broken wrist), it can be better to immobilise only the affected joint, and do so in a way that enables lots of movements of the surrounding joints; then facilitate some loading of the affected joint as soon as the bone is ready, to reduce overall recovery time and overall time immobilised.

We know that immobilising joints is often one of the worst things for them due to it weakening all surrounding soft tissues and often contributing to longer recovery times to restore the movement lost from prolonged immobility. 

This concept ties into the overall general idea that pure rest is often not actually that great for us. Though it historically is often promoted as the best option for treating injuries, it is interesting to note that as time has gone on, more and more, the negatives of rest and immobility are highlighted, and trying to rest for as short a duration as possible and keep everything else moving as much as possible is a consistent theme. 

Always great to hear from other professions to have a better understanding of what they each do and know when it is appropriate to refer a patient on.

Frances