‘Life can only be understood backwards.’

Søren Kierkegaard

‘So you want to be a masseur, Worsfold?’ spat my chemistry teacher Dr Davies sarcastically on hearing that I had applied for physiotherapy training. I had wanted to be a chemistry teacher, but changed my mind at the last minute. I wanted to ‘do something to help people’ and I loved science. I guess I kind of fell into physiotherapy…well, it certainly wasn’t a clutching embrace that’s for sure. CLICK!

1980’s

Liverpool. Nineteen eighty four. Amidst a fabulous Militant left wing council I crash landed in an ex-nurses residence with 14 young women wannabe physiotherapists. I remember my first night away from home. Supine on a single bed, The Style Council’s ‘Cafe Bleu’ rattling out of my stereo portable cassette tape recorder across a smoke filled room.

I’m staring down at M. Dena Gardiner’s ‘Principles of Exercise Therapy’. I’m thinking ‘this is the last night of my life I will know nothing about physiotherapy’ (ahem). CLICK!

The training was bizarre and I really wasn’t prepared for it. We had to sign in and sign out of the ‘School of Physiotherapy’. The curriculum was dominated by exercise and electrotherapy; there were the dreaded CARB’s (Continuous Assessment Record Books) to complete and we spent a lot of time with Short Wave Diathermy coils and calculating Infra Red Lamp distances from student’s scorched limbs. CLICK!

I’m scraping through the training but seeing a lot of great live music: The Smiths, Aztec Camera, The Style Council and Billy Bragg. Somehow I make it to the end of the course, with a memorable elective placement in mental health; at last somewhere I felt I belonged. But the overriding feeling about physiotherapy among my cohort was pessimistic: ‘it doesn’t make much difference’ and ‘we’re at the bottom of the medical hierarchy’ were common comments. Plus ça change…CLICK!

I was looking for a job, and then I found a job. It’s nineteen eighty seven. Musculoskeletal physiotherapy is not a thing yet and I spend my days seeing four patients every half hour! I am working alongside physiotherapists who trained in the 1950’s. Their version of physiotherapy was a vibrant mix of electrotherapy, very physical (and often painful) hands-on massage (and sometimes Cyriax type manipulation) with a big emphasis on exercising into pain. Looking back it’s perplexing to think how this ‘exercising into pain’ got lost in the mix somewhere, in the decades that followed.

At this time there were few directions for an aspiring physiotherapist to go; it was Cyriax, McKenzie or Maitland. There were no RCT’s, no computers, no internet and there were no formal post graduate courses except for the convoluted clinical pathway to MACP membership (Manipulation Association of Chartered Physiotherapists – as it was then).

I desperately wanted to learn the Maitland approach and the only way to do this was to buy the books and / or learn on face-to-face, hands-on courses. This was The Holy Grail. The Magic Bullet. It was a tremendously powerful emotional pull. And some of us were enthused by it – but how to learn when we only had textbooks, word of mouth, telephones wired to the wall and a handful of gurus with their small-font black and white box adverts in the journal ‘Physiotherapy’ (Yes – weekend course adverts in a journal).

It’s so hard to convey and imagine what it was like compared to nowadays, where everyone and everything is media-incontinent, leaking information and opinion everywhere and all the time (says he). So, I ordered Maitland’s ‘Vertebral Manipulation’ from the local bookshop (six weeks delivery, no less) and set to work deciphering this mystical occult art. CLICK!

1990’s

The 1990’s were an altogether more interesting decade professionally. Looking back it was a pivotal time for what was to become so called musculoskeletal physiotherapy. For me, David Butler’s ‘Mobilisation of the Nervous System’ was a landmark publication: it was erudite, humble and really paved the way for physiotherapists to start looking further than those blessed joints; to date ‘manual therapy’ had been content to push on joints (albeit in an ever so sophisticated way). But here – in Butler’s publication – was a body of work that raised questions about anatomical structures other than the joints.

I remember attending one of Butler’s first courses, in Harrogate, England – must have been the late eighties – at Robin Blake’s physiotherapy practice and there was a real sense of something exciting taking place.

What is ironic – in retrospect – was the management approach adopted for so called ‘adverse mechanical tension in the nervous system’. It was the same approach that was being used for the joints. ‘Mobilise for 30 seconds, re-assess. Mobilise for 30 seconds, re-assess…’ I remember one high profile physiotherapist at a West London clinic recalling that private patients would get three lots of 30 seconds of ‘upper limb tension test one’ mobilisations as their only treatment!

Of course Louis Gifford was also publishing and lecturing around this time and his publications with the Physiotherapy Pain Association were ground-breaking in their depth, rigour and clinical applicability.

And alongside Butler and Gifford’s work was Waddell’s game-changer ‘The Back Pain Revolution’. This was the early 1990’s and it may come as a surprise but physiotherapists were considering psychosocial factors – stress, mood and lifestyle and even ‘sensitised states’ (although it went by another name “para / sympathetic nervous system arousal” – doesn’t get much mention these days does it? Dorothy ‘Duffy’ Sweatman anyone?). CLICK!

In 1991 I opted for a full time MSc embarking on a study of self-efficacy in low back pain, at the University of Southampton. I had been inspired by work coming out of so called ‘pain clinics’ that suggested ‘confidence’ was key to increasing function in spinal pain.

Unfortunately the spinal surgeons refused to grant me permission to interview ‘their patients’ as they saw ‘absolutely no scientific merit’ in a study of the psychology of low back pain. Even my contemporaries (and they must have been a rare bunch because this was only one of two MSc courses available to physiotherapists in 1991) were telling me surely my research interests should be left to the psychologists – ‘what has this to do with physiotherapists?’ they asked.

I complete the research (guess what – psychological factors were the strongest predictors of recovery!) but I nearly fail the course due to my phobia of speaking in public and presenting at a Conference was part of the course. CLICK!

Next, I toiled around South London – bingeing on the weekend course circuit: Toby Hall, Mark Bender, Kinetic Control and Combined Movements. At the end of the century – 1999 – I started on what was referred to then as ‘the manips course’ at University of Brighton. CLICK!

2000’s

Around the time of my ‘manips course’, I recall we were just starting to discuss the limitations of the purely biomechanical approach and starting to acknowledge the short term neurophysiological effects of ‘manipulative approaches’ and as I have mentioned earlier, ‘psychosocial factors’ were included in our clinical reasoning process. But I think it is also true to say that with the dawn of the ‘multifidus revolution’ all this ‘psychological stuff’ was overshadowed. Now, the emphasis was on getting everyone with low back pain  to contract their ‘Transversus’ and their ‘Multifidus’ at will.

In retrospect, this was perhaps the start of the Evidence (read ‘Laboratory’) Based feeding frenzy that followed (and which is still clearly evident today). Findings from small lab-based experimental studies were immediately translated into clinical practice with ‘lab based findings’ trumping the burgeoning ‘psychosocial / pain’ literature.

It was as if there was just one philosophy of ‘treatment’ that hinged upon the atomisation of rehabilitation into minute, abstract and esoteric movements. The light had been shone on a minuscule aspect of rehabilitation; wherever our cherished physiotherapy researchers cared to stick their fine-wire EMG electrodes, we clinicians would happily follow.

I have a haunting memory of this time: picture the scene…slanting sunlight in a dusty South London NHS hospital physiotherapy gym, row upon row of ‘low back pain patients’, sitting watching a video-taped educational film on a TV that’s the size of a truck, telling them how their pain was caused by ‘instability and excessive movement of the vertebrae and pelvis’ – as a faceless and discombobulated mannequin dummy jerked across the TV screen, like a puppet on a string. The message was clear: ‘you have pain because you’re falling apart – now simply learn to tense and tighten the back muscles…and all will be well…’

It was simply impossible to get patients to contract these multifidus muscles: sitting up straight, belly out and straining, purple faced, with their thumb nails digging into the flesh over their poor old spine. Joint and nerve mobilisation had a new friend: sophisticated and obscure you could almost guarantee that nobody on an NHS waiting list could perform these exercises. CLICK!

Looking back from 2018…

So, what have I learnt from reflecting on my three decades in physiotherapy? Oh my word…

Perhaps physiotherapy can only be understood backwards? Because the image that I see when I look back at ‘physiotherapy’ is like the movement of the sea – the tide – ebbing and flowing, moving in and moving out. I see a clear shifting of the emphasis in our work pulling this way and that, as we lurch from this Guru, to that evidence and back again.

Like a physiotherapist after a weekend course, we – as a profession – become obsessed and over focused upon just one thing. It looms large for a while and then we move away and towards something else, and it takes time – sometimes a long time – for us to achieve a balance.

In this way – at an individual level – we become more rounded as we learn and experience more of (clinical) life, but I also think it is true for us as a profession – like a pebble we are becoming more rounded as we visit and revisit, over and over, different aspects of our work, edging ever-nearer the truth.

The second thing I notice is this: I think it is a trick of the light that we physiotherapists were concretely 100% biomedical in the recent past. This certainly was not the case in the UK even 25 years ago, although from contemporary commentaries, we would be led to believe that this was the case, that somehow we now stand on virgin territory, when in reality we simply continue to struggle to anchor what we currently believe about the human condition in the chaotic stormy sea of clinical work, as we have always done and always will do.

And this past I have described – it is shared by each and everyone of us, warts and all: the electrotherapy, the joint mobilisations, why even the multifidus contractions! It’s not pretty is it? But this is your professional lineage and surely we all have a responsibility to find a kind of peace with this and in so doing acknowledge that by virtue of science, we will be wrong again, and again and again. There is no exemption from this rule, for most of what we believe today will be shown to be wrong.

Look! The Orthopaedic-surgery-super-high-tech-cash-cow trundles merrily past in the background – in blissful ignorance of contemporary ‘pain science’ and psychology etc. etc. But us physiotherapists, we are tackling some tough tough home truths – and of this we should be collectively PROUD.

And although this is not the first time we have been here – struggling to connect the body and the mind in a culture that demands a quick fix, in a culture that is driven by profit and not common sense – one thing is very different about today: we now have myriad powerful ways to connect and communicate with each other and share our professional thoughts, beliefs, fears and anxieties than we ever could have dreamt in the past. The potential for changing professional and public beliefs today is literally awe-inspiring.

So let’s not waste this opportunity, let’s harness this power wisely, with humility and with grace – as indeed we all do every clinical day with those who entrust themselves in our care, in a positive supportive climate – as we once again turn with the tide towards the truth, but together as one and not alone this time.

Yes! The future lies quite literally – and oh the irony! – in your hands.