Musculoskeletal Physiotherapy has gone through many transitions over the years. Its capacity for reinvention has been one of the profession's strong points. Manual therapy was as early guise but rightly seen as too passive and limited.
The next significant shift was into exercise-based treatments. Exercise therapy took several forms; whether it was specific stretches or strengthening exercises or more technical motor control or core exercises. Whilst an update on the manual therapy approach, it still had limitations. We discovered that stress and poor sleep were much more significant predictors of episodes of pain, so just giving exercises felt limited.
The next big movement was into a more technical term called the biopsychosocial model of practice. What this entailed was looking more at pain science, psychological and social factors in how we managed patients. Whilst everyone agreed that this was absolutely the way forward, nobody knew exactly how to apply this model. Ever since this change, physiotherapy has had a hard time understanding how to put everything into practice. Consequently, physiotherapists tend to do a little bit of everything - pain science, manual therapy, exercise prescription. It's not entirely flawed, but maybe there's a better way - a new evolution.
The evolution of physiotherapy...
When you think of health coaching, most people will think of personal trainers. They promote good health, and they coach you to stay motivated. You may also have a good GP who guides you with how to improve your health rather than just helping you with symptom management. There are issues here, though. Your GP generally doesn't have the time to spend an hour guiding you through diet and lifestyle medicine. Their system is pretty strict on appointment times, and they have pretty sick people to be seeing. In my opinion, their medical training is a little too symptom-focused too. It can be hard to convince a GP that you need a bit more guidance of how to perform better at your health when you have no 'significant' health issue or illness, and your blood panel, for the most part, looks fine. Personal trainers may get a little lost if you start discussing your slightly elevated cholesterol or blood glucose, or why you keep waking up at 3 am and can't get back to sleep.
So what is the solution?
One solution could be to put together a team of health practitioners who can all bring their area of expertise to the table. Your GP could coordinate with a dietician, an exercise physiologist and a psychologist. Strength in numbers etc. My issue with this is often you find patients receive different messages, and they become a little confused. It also defines the patient into silos and underestimates the connective nature of the body.
Perhaps their diet causes low-grade inflammation in the body, which is then leading to joint pain and stiffness - leading to more negative thinking due to inflammation existing not just in the body but the brain. One practitioner may tell the patient they have weak glutes and core, whilst another wants to address how they manage negative thinking with a cognitive behavioural approach. The dietician wants them to count calories and utilise portion control to help lose some weight. These ideas aren't wrong, but they don't all tie-in within a bigger picture. What is needed is someone who can connect all these systems like a conductor of health.
This is where I believe physiotherapists could be ideal candidates to step up. We consider the fundamentals of health to be diet, sleep, stress management, human connection and exercise. These are all areas a good physiotherapist can guide you on. They have a level of medical training that with a little up-skilling can allow them to understand blood chemistry from a fundamental health perspective. Or even without looking at blood chemistry getting an excellent clinical picture from detailed patient history.
- Does the patient have a pattern suggestive of a systemic issue like inflammation?
- Do they have a purely biomechanical problem?
- Are they waking up because they have a cortisol response at 2 am because they have a dysfunctional metabolism?
- Are they poorly managing their stress levels and using their phone immediately before bed?
- Do they keep getting sick because they have a vitamin D deficiency?
- Is their diet too high in sugar, leading to a weakened immune system?
This level of investigation is what a skilled health detective would do.
Behaviour change is the key
When it comes to health coaching, we need to have a better understanding of behaviour change. Physios have been prescribing exercises for years, so we know all about this and the variation in patient adherence. Some of us have a natural discipline that makes any new behaviour easy to implement - I am fortunately one of those people for most things. For the majority, though, knowing what to do and doing it are entirely different things. This is where a good health coach can step in.
In our practice, we learnt this the hard way initially, with inconsistent results. We became frustrated when patients didn't follow the plan we outlined. We had experienced this with patients not always completing their exercises, but this felt different.
We believed in this approach as a way to change individuals lives much more than performing exercises. We wanted this result more. At first, we blamed the patients but soon realised it wasn't the patient's fault; it was our lack of skill with behaviour change.
A good health coach knows how to allow the individual to make this decision for themselves and figure out the 'why?' from the patient. This is not emphasised enough within traditional physiotherapy training - but with some additional study, can be implemented well.
Why should physio's be motivated to adopt this practice?
The benefit to the physio should also not be underestimated. There's a level of job satisfaction I never experienced to this degree before. I now receive messages on my phone from patients, which are mostly photos. I get sent beautiful sunrises, healthy food plates, and step counts for the day. Each image is a real pleasure to see. I get to hear how patients are down to the weight they were 20 years previously. Or how their GP told them their blood glucose was the best it had ever been, or how they no longer have fatty liver. They may even come off medications like statins, reflux meds, blood pressure meds following their GP's advice.
All in all, it's a much more rewarding job in this evolved form.
What do we need to make this shift? It's all about finding that thing we all had when we started this profession - passion. We all chose to work within health for a reason. One would hope that reason, to some extent, was to help people. For many though that initial passion can wear off somewhat but this evolution can spark it again and push it further. One of my favourite Doctors in the health space Dr Unwin talks about 'hope' and how it's this that can be the driver for change. We combine passion, hope and a little extra time with learning a few new things and we may just have found everything modern physiotherapy should be.