Is your physiotherapist providing best practice care?

Many of us who have suffered from a particular injury and have sought help from a physiotherapist may have had a very different experience between different physiotherapy practices and individual physiotherapists. 

Thankfully, a very high-quality, systematic review published in Perth in 2019 has clearly defined what best practice looks like in managing musculoskeletal pain presentations.

See below for the full checklist of the 11 recommendations:

1. Care should be patient-centred. This includes care that responds to the individual context of the patient. 

Physio’s should be working with their clients in a collaborative manner using their individual goals at the forefront. For example, if a clients’ goal is to be able to enjoy a walk around the park with their wife and dog then we don’t need to implement advanced exercise for running.

2. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions.

This is an integral part of a physiotherapist’s role. Carefully looking out for information in the client’s story, medical/family history, and physical assessment can screen for features that are driven by non-musculoskeletal causes such as auto-immune disorders, cancers, vascular issues or similar. You could expect some specific questions around these topics and it’s important to mention any general health issues.

3. Assess for psychosocial factors.

Recovery from most musculoskeletal conditions are influenced by the client’s expectations about their injury, whether there is any fear of movement, and/or negative beliefs around pain and injury. Stress can also play a big role in injury outcomes. Your physiotherapist may ask some questions or provide you with questionnaire’s around these factors.

4. Radiological imaging is discouraged unless:

a.     Serious pathology suspected

b.     There has been unsatisfactory response to conservative care or unexplained progression of signs and symptoms

c.     It is likely to change management

For many musculoskeletal pain presentation, radiological imaging or ‘scans’ aren’t indicated and can in fact slow down recovery or distract from the actual root causes of the issue. It is crucial to interpret scans as part of the entire clinical picture and how they fit in to a clients’ story. Studies have shown that many degenerative radiological findings appear in people who don’t have any symptoms or pain. This could include bone spurs, disc degeneration, disc bulges, osteoarthritis, tendon tears, meniscus tears. Physio’s should always treat the person and not the scan.

5. Undertake a physical examination, which could include neurological screening tests, assessment of mobility and/or muscle strength.

Your physiotherapist should use the physical examination to further rule out red flags, screen for injury involvement in other areas of the body, whether they can change or modulate symptoms, and work out the main factors that are contributing to a person’s issue. Your physio should use assessments that are objective and can be recorded to evaluate progress. This could include measurable range of motion, functional performance tests, or specific strength measures using a hand-held dynamometer (or similar).

6. Patient progress should be evaluated including the use of outcome measures/criteria.

Your physiotherapist should use a combination of outcome measures (evidence-based questionnaires), outcome criteria (objective measure milestones), or comparing objective measures to normative values (comparisons of expected measures for a similar population). This helps to guide progressions, identifying people at risk of re-injury, and can be used as a motivation tool.

7. Provide patients with education/information about their condition and management options.

 Some key information that should be provided in your first physiotherapy appointment include:

·      Provisional Diagnosis and contributing factors to the condition

·      Prognosis or expected time frame for recovery and physiotherapy management

·      Things To Avoid that are slowing recovery or contributing to the issue

·      Things To Help settle down the issue and break the cycle of symptoms

·      Clear & Simple Education about the condition that is tailored to the clients understanding

·      Treatment & Management Plan like a roadmap from where the client is now to where they want to get to

·      Onward Referral information or co-management if required

8. Provide management addressing physical activity and/or exercise.

For most musculoskeletal conditions, integrating some appropriate physical activity and exercise can be critical in enhancing recovery and also benefits overall health. Key benefits include:

·      General exercise has an analgesic (pain-relieving effect) on the brain/body

·      Exercise can release positive brain neuro-chemicals such as dopamine, serotonin, and oxytocin (if exercising in a group/with a friend). This can reduce stress/anxiety that could be contributing to the pain

·      Exercise helps the cardiovascular system which builds fitness/prevents disease, the body’s immune/respiratory system to fight off infection, and helps bone density

·      General exercise helps the lymphatic system remove waste products, and inflammation/swelling at a faster rate

9. Apply manual therapy/other passive treatments only as an adjunct to other evidence-based treatments.

Manual therapy, dry needling and other passive treatments should only be used to assist with recovery to complement the cornerstones of habit change, building client’s capacity with strength and mobility, and optimising general health. There is great evidence that a multi-modal approach in combining manual therapy with education and exercise yields the best results with most musculoskeletal conditions.

10. Unless specifically indicated (e.g. red flag condition), offer evidence-informed non-surgical care prior to surgery.

Studies have repeatedly shown that pre-operative care and sometimes a pre-habilitation program can not only improve post-surgical outcomes but can improve a person’s condition that surgery can be postponed or avoided. This approach is now best practice with the support of many surgeons.

11. Facilitate continuation or resumption of work/meaningful activities.

It is very important for people to maintain their identity and purpose while dealing with a musculoskeletal condition and your physiotherapist can help facilitate this by encouraging a continuation of work, hobbies, and exercise. Modifications of load, intensity or time can be introduced to enable a continued participation in the things you love or have to keep up. Continuing these activities has been proven to improve recovery times and reduce the risk of developing chronic pain.

If you are looking for a comprehensive assessment and treatment plan to overcome injury and pain, reach out to us. We’d love to help!

Reference:

https://bjsm.bmj.com/content/54/2/79