Introduction
I think about this all the time. In trying to provide an exceptional service I read a lot about new assessment or treatment techniques, new equipment, or new types of exercises. The more I think about it the more I accept that high quality physio is underpinned by the quality of the human interaction.
I also see plenty of people who tell me about their experiences of "bad physio". This gives me a good insight into what people really don't value in a physio setting.
I have written this blog to highlight what I think people should be expecting from a good quality physiotherapy appointment. I believe the days of a quick chat and “hopping up on the bed” are over. I hope to empower members of the public to be able to identify “good physio” and avoid the pitfalls of multiple appointments without a clear diagnosis or treatment plan.
I'm going to skip the step of actually finding a physio and booking an appointment for now. Let's start at the first appointment.
Starting at the Start
1) You should have a chance to tell your story without interruption. Typically people are quite good at providing the required information, a small bit of prompting is okay. Far too often the physio will try to dictate the conversation with strict "proforma" style questions. You should feel encouraged to share as much detail as you think is relevant. Often people will have important info but don't share it because they feel it may be "silly". This is not the case, if it matters to you and you think it may be relevant it is worth discussing!
2) There should be a discussion about your medical history. Other medical conditions you have, physical or mental, can contribute to the issue that brings you to see a physio. They can also dictate treatment options. If you see a physio and there is no discussion about your broader health I would be questioning the quality of care.
3) You should be encouraged to explain how your problem is affecting your lifestyle. A sore shoulder for someone who works in an office and a sore shoulder for a self employed plasterer can have completely different ramifications. The context of your problem in your current lifestyle is important to establish. Again, this can dictate treatment.
With all the relevant information gathered it can be very useful to learn about your expectations of coming to a physio session.
You Must Be on the Same Page
1) You should have a chance to explain exactly what you’re looking to get out of physiotherapy. This applies to the overall outcome and to the types of strategies used to get there. In terms of the outcome, are you expecting to be 100% pain free after one session or is this a long term issue you would like to get on top of over time? Being on the same page with expectations is really important.
Strategies used to reach your preferred outcome are basically which types of treatments are used. Are you expecting a massage or a challenging exercise programme, or would you really just like to understand your issue more clearly? I’m sure you can see how a mismatch between the type of treatment expected and treatment provided may limit progress!
2) Being able to discuss fears or worries about your issue is important. If there is a concern deep down that your issue may be something serious and this isn’t addressed during the session it is difficult to move past this. A good example is someone with back pain being terrified that it is a “disc problem”. Maybe they have a friend who had a spinal surgery and they mentioned discs. It won't come to the surface unless it is discussed.
3) Do you have a “hunch” about what is going on? I always like to discuss this. Some people have an idea what their problem is and may have done some research. This can be very valuable information. Sometimes it can be quite accurate and this can be helpful! Clearly, this isn’t always the case and being able to discuss the difference between what you think the problem is and what was found online is really helpful.
With these basics covered you should be well on your way to a “good physio” experience.
Why the Physical Examination Is so Important
Before there is any physical examination your physio should already have a good idea of what they think the problem is. The information gathered from your discussion is hugely valuable when considering different diagnoses. The purpose of the examination is really to rule in or rule out the suspected diagnoses. I think any good physical examination should include the following;
1) The area causing trouble and the surrounding area has to be actually looked at. By this, I mean you have to be able to see the skin. Things like muscle wasting, swelling, colour changes and joint shape can all give good clues as to what is going on. I have come across plenty of cases where not properly visually examining the area has led to missed diagnoses. It can be a bit awkward exposing areas of your body that are normally covered up but it is an important part of any assessment.
2) You have to move! Watching how you perform different movements provides loads of useful information. Being asked to raise your arms overhead, bend forwards or backwards or squat down are all quite common things to be asked to do depending on what your problem is. These tasks are usually similar to everyday movements which increases how valuable they are. If your examination doesn’t involve anything like this I would be starting to question how much thought your physio is putting into a diagnosis.
3) “Hands on” testing of how body parts are working is usually needed. Most of the time it should be done at more than one location. For example, it is possible for shoulder or upper arm pain to be caused by nerve root compression in your neck. In this scenario, if it was just your shoulder that was examined you could very easily miss the cause of your problem. During these tests you should be informed about what is going on. In the example above, it would be good practice to test your reflexes and sensation in the skin too. Having this done without it being explained as part of a nerve function test may seem quite weird!
At this point there should be a conclusion drawn by your physio about what is causing your problem.
What About the Treatment?
I think the first step should be sitting back down and discussing your diagnosis. This relates back to “being on the same page”. Without an understanding of what the problem is you cannot confidently take treatment any further. It is okay to ask your physio what they think is going on exactly! Discussing your diagnosis allows a few important factors to be discussed.
1) Is this a serious problem? The majority of the time seeing a physio about a musculoskeletal pain you have is appropriate. However, there are times when a physio needs to refer you elsewhere. For example, you may be referred to a rheumatologist if your symptoms sound inflammatory in nature. Usually, your physio should be able to reassure you that you are in the right place and hopefully put your mind at ease that there is no evidence something sinister is going on and that there is no serious structural damage to your body.
2) Outlining how long it usually takes for your problem to get better is really important. Although it’s not always possible to give exact time frames your physio should have a good idea how long this will be. This allows you to come to terms with your problem and can actually make your situation less stressful.
3) What are the options to help get better? This needs to be discussed. There is never just one way to move forward with a problem. This is where your physio’s knowledge of the scientific evidence is important. They should be able to make suggestions about which treatment strategies can be most useful. If you have a strong preference for one particular type of treatment this should be considered too. If you encounter a physio who seems fixated on a particular type of treatment technique I would encourage you to ask them if there are other options.
Doing nothing is also a legitimate treatment option! If you feel like you understand your problem, are happy with what’s likely to happen and feel like you don’t need anymore help that is okay. I regularly see people who develop back pain for one session only. A lot of the time once I explain that acute back pain usually settles by itself they are happy to see how things go. Most of the time when I follow up with them a few weeks later they are fine!
This blog isn’t the place to compare one type of treatment to another but I strongly believe an attempt should be made to help you help yourself. If the only treatment recommended involves you lying on the bed for multiple sessions and “having stuff done to you” I would be questioning the quality of the care you are receiving.
Okay, with these bases covered I hope you have an idea of what “good physio” should look like. I completely accept that these are my thoughts and other physios may disagree. That’s okay! However, I do feel confident that what I have proposed here is in keeping with modern, evidence based best practice.
As always, I am happy to discuss any of these points further. Feel free to get in touch!
Thanks for reading,
Patrick Carroll