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The reliance on passive interventions in rehab & pain management driven by lack of S&C knowledge?

Updated: Apr 18, 2023

What in the healthCARE are we doing?

Strength & conditioning (S&C) and physiotherapy are often considered separate entities, working from their own individual paradigms. Granted, some people don't know what S&C actually is as a subject matter outside of elite athletic populations. Certainly in regards to understanding the profession and its relevance/role in rehabilitation. However, logically and pragmatically speaking, physiotherapy and S&C are on a continuum that merge to form a rehabilitative pathway to help someone return back to function & performance, whatever that may be for the individual. At the very core, both domains are about movement, whether that is restorative, or an expression of movement in a highly contextual elite performance setting. Intuitively then, taking someone through rehabilitation often can't be realised without a good grounding in the theoretical underpinnings of S&C; without a thorough understanding of things like stress adaptation, physiology, biomechanics, skill acquisition and training principles. Sometimes people get caught up with the idea S&C consists of just a load of gym bro's lifting things. Ok, ok, it often still is.

Not too long ago a peer in my S&C masters cohort wrote an article in the British Journal of Sports Medicine. The title was...

"S&C or Physiotherapy - who are the real exercise professionals?".

... one that probably got a few people in both professions to shuffle uncomfortably in their seat. Uzo Ehiogu, the author, is a physiotherapist. He writes candidly about the potential for physiotherapy as a profession to be "left behind"... To quote a segment which tries to do best in summarising his views (I would still recommend you read the full article for greater context)

"Historically, exercise prescription has been the preserve of the physiotherapy profession as a default. However, this precedent has not kept pace with the professional developments in S&C, exercise science and S&C research. I would argue that the physiotherapy profession has fallen out of step with the emerging S&C profession in some regards...The physiotherapist wanting to use exercise as a primary mode of intervention and its associated sub specialities; for example in skill acquisition, programming, biomechanics, physiology, exercise techniques, and applied research methods cannot “hope” to acquire this level of expertise without a protracted commitment to continued professional development."

I think this is a insightful perspective and one that validates some of my views formed by my experiences and interactions over the years. Additionally, as a side note, what appeals to me in this piece is Uzo's ability to identify their own limitations in practice, and seek out further education in a related field. We always talk about the importance of interdisciplinary approaches and nothing says that better than a practitioner diversifying their skillset in a related profession. This is something which I also aspired to do and continue to do so. Many moons ago I attained qualifications in sports massage therapy and instrument assisted massage therapy. I didn't necessarily want to become a sole practitioner in that field, I just wanted to have a better understanding of the principles. It means having some skin in the game, bringing weight to an opinion on such matters, which only increases quality discussion and critical insight.

As Uzo suggests in his article, the majority of people who are injured or with musculoskeletal pain, would aim to seek out a physiotherapist to get better. It is widely accepted they are the 'go to' professionals designated to manage individuals back to function & performance. There are of course some logical reasons as to why people seek out physiotherapists. It is a profession that is firmly established. In part due to its clinical / diagnostic roots and it being regulated by law; all physiotherapists must register with the Health and Care Professions Council to practice. You can of course always have people pretend to be something they are not, and indeed most employers in any profession will ask for the required qualification before practice, but it does add perceived credibility amongst the public.

There are no such barriers to practice S&C. Point being, anyone can call themselves an S&C coach, or can say they practice S&C. This makes it difficult from a quality assurance perspective for the public to discern real from fake. Not that a stamp of approvals and higher education is always fool proof, but for someone like myself who holds a masters in S&C, and have attained qualifications through the UKSCA (UK strength and conditioning association) who aim to set professional standards, I am essentially thrown in the same bracket as someone who just hashtags S&C on Instagram. Ultimately, like with most people who are passionate about their work, I want to offer the best service possible, and that's why I did it. Not because it is an essential requirement in private practice outside elite sports. Additionally, this can also be said for sports rehabilitation graduates, regardless of the good work from BASRaT (British Association of Sport Rehabilitators) in terms of developing professional regulatory standards. The bigger issue is as mentioned previously; I just don't think people in general really know the skillset of S&C or sports rehab professionals outside of their specific elite sport domains. Because of this I have even known some sports rehab graduates go back to university just so they can attain the title of a physiotherapist, simply to make themselves more appealing/marketable in private practice.

So why is this article an important thing to contemplate?

Well, if the majority of physiotherapists by and large aren't equipped with the adequate education/skillset to implement progressive and extensive exercise interventions, then is this just band aid healthcare, only treating for short term relief rather than building for long term success? Secondary to that, this notion in of itself means physiotherapists are designating themselves as a diagnostic / acute management & passive intervention profession, which I believe is a huge issue within rehabilitation. That is, it can just create an over reliance on the importance and value of passive interventions in practice, which unfortunately in my experience returns less than ideal outcomes.

Passive interventions are treatments performed by a physiotherapist and many other professions (it's important to state this is not just a physiotherapy issue, perhaps even more relevant to Chiropractic, manual therapists, Osteopaths etc). Passive interventions are things such as massage, needling/acupuncture or joint manipulation and mobilisation - considered passive in nature; the patient to be a submissive recipient of treatment.

Without a doubt there is a high demand for treatments like these, as primarily we seek out passive interventions because we want to get some immediate pain relief / find comfort. It is also important to note that people have their own expectations of what treatment and care should look like, especially when in pain. That doesn't mean practitioners across the spectrum of healthcare should just hand out what ever treatment a patient wants rather than needs, but it is interesting to consider how this influences treatment options.

For context. I won't deny that these passive interventions can be beneficial, especially in acute pain management, although I often expect 'regression to the mean' I.e injury/pain often returns to baseline with time regardless of intervention, making it difficult to assign value to treatments. I'm also not going to do a systematic review on all the evidence for each passive intervention (it is probably unfair to lump them together from an efficacy POV), but these treatments are usually NOT beneficial for the reasons many practitioners claim them to be, and that is a problem. Just to throw out a few repeated classics "re-aligning the spine with an adjustment" or "breaking down knots" - they are just words, that perpetuate misunderstanding and role of significance. I suggest anyone who wants to listen to a great podcast on everything manual therapy, then listen to the discussion between Chad Cook and Adam Meakins here.

What can be heavily debated is the degree to which these interventions are beneficial and the their place in the bigger picture of rehabilitation. In the same way it is highly questionable for a GP advocating paracetamol as a treatment for chronic back pain. The point is, if we are looking for long term solutions and improvements at the baseline, active (exercise/training) interventions should be without a doubt the primary focus of rehabilitation for the majority. Yes, everyone doesn't need an exercise intervention in every scenario, but what are we trying to achieve in the long run in the greater context of healthcare?

There are of course some fantastic physio's who operate in this way. We undoubtedly value an interdisciplinary approach, and those who we do work with all share a commonality; they have branched into S&C, or at the very least personally invested in training. They often spend less time in the clinic room and more time getting people up and moving. We must remember the benefit to exercise is not solely down to the potential for neurophysiological & structural adaptations, but because of patient self efficacy, competence and autonomy, and the wider impact on health. Yes, passive interventions may facilitate a window of opportunity to get a patient to move more (hopefully without load of meaningless language attached to it) but if exercise is not being advocated for as primary for most people, then it really only highlights to me that there are perhaps huge differences in the actual aims and purpose of rehabilitation between professional perspectives i.e. alleviate pain vs. nurturing an environment to help someone feel like they can run through a brick wall. "But Jamie, not everyone is compliant with exercise prescription..." then try to do a better job in creating an environment / value in enhancing patient understanding / education.

At the end of the day, although passive techniques may have a role to play in reducing immediate discomfort, you should be wary if the use of one or more of these passive treatments is the only intervention being administered.

I think this is compounded when looking at ''evidenced based'' active interventions being implemented across rehabilitation research. From ACL recovery, to osteoarthritis, to something as simple as tendinopathy. For example, it is well-evidenced that a hip replacement can be beneficial as a treatment for those suffering with moderate to advanced hip osteoarthritis. And it would appear anyone with hip pain over 50 is cueing up for one... However, we are less sure to the degree active interventions can help mitigate the necessity for surgery. This primarily can be due to the low bar we set in physical rehabilitation intervention studies. Most interventions are measured over 8-12 weeks, and many of these active interventions are chronically undercooked, defined as 'low intensity' = therabands & mobility drills. It also depends on what we desire those clinical & patient outcomes to be, and how we define return to function? Does that mean reduced pain? Manageable pain? Walking? Getting up and down stairs? Etc. Ultimately, it's always N=1, you make the best decision for the person in front of you based on all the evidence (research & clinical judgement). But the issue becomes apparent. If across the board, there is a lack of quality evidence, and also the lack of education of S&C in practice, then we are just driving more people to choose painkillers and passive/surgical interventions than is actually warranted. Is that really healthCARE?

Unfortunately, this is the reality, personal anecdotes coming up; I've come across too many people who were let down by these approaches. People in pain. People advised to undergo surgeries when not needed. People told to not exercise / fear mongering around specific exercises. People who were told things that are simply not true. People who become reliant on treatments, and questioning their own sense of competence. People who were even left with no explanation, other than you need to be 'fixed'. I'm an S&C coach, who is always happy to refer outside of my scope of practice. But I don't know if rehabilitation outside of acute injury care IS outside of my scope of practice. I think S&C in the private sector IS the professional best placed for the majority of rehabilitation care. Perhaps, along with continued education for primary care practitioners, that is the message we should try to be persistent with across society in general. Instead of only 35.7% of GPs being at least ‘somewhat familiar’ with current exercise guidance.... and that guidance being 'couch to 5k'. Common, we are failing miserably across the board here. When people (yes, multiple) have bounced off numerous difference physio's, chiropractic, a handful of manual therapists, UNTIL as a last resort, they actually start adhering to the laws of stress adaptation with appropriately graded exercise over an appropriate time frame, and supported in such a way that they feel like they can do... Then we must realise 'rehabilitation' is largely failing.


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