Why going to a Pain Clinic can be a really good step to recovery

When the physiotherapist mentioned going to a Pain Clinic, everything about it that I could find suggested to me that this was a last resort – a place that you go once you have lost every last vestige of hope that you can get better and just want to manage the pain to try to find a way to get through the minutes and hours of an agonized existence. And talking with a number of other people in pain, this perception is very common, and none of the things that I could find online change that view.

However, the reality was so very different, and this is why I wanted to write this to help others to get the help that they need faster.

They never dismiss your pain

I can imagine that one of the challenges for Health Care Professionals is when they have to admit that something is complex and they don’t really know the answer. The downside of this is that thousands of people every year are dismissed by comments and inferences that imply that the pain is ‘all in their head’. You only need to take to Twitter or patient forums to hear the things that people have been told (or at least how they have interpreted comments from Doctors and Physiotherapists).

At the pain clinic, dealing with serious pain is their ‘thing’ and they are overflowing with compassion, knowledge, support and genuine interest in your pain. This alone is a huge relief, when you have been spending months battling to get people to listen the symptoms and take them seriously. It feels like getting into a comforting, warm bath! Plus they have models and simple explanations that help you to make sense of how your life is unravelling and what you can do about it.

One model that was enlightening for me was the ‘pain triangle’ that they said was universal in serious pain – where the relentlessness and intensity of it makes you feel helpless and hopeless, and your incapacity and reliance on others then drives feeling worthless. Then each point of this ‘helpless, hopeless, worthless’ triangle reinforces the other points, dragging you lower and lower until you can find something to break out of the vicious cycle.

They really want to get to the root cause

The next bit of brilliant news at the pain clinic is that they profoundly believe that your pain has a cause and that with work, they can find it. I felt that there was almost a detective vibe – where they are searching for the cause with different clues, hypotheses and points of evidence. They listen intently to every clue that you can give them, weighing it and thinking about what it could mean in a medical sense.

The pain clinic felt different. How? Well, I sometimes joke that when you see a consultant, they only have the 3 N’s (kNife, Needle or Nothing) and physiotherapists only have the 3 P’s (Poke, Push or Pray). This is of course brutally unfair and negates all of the knowledge and complexity of what they do, but as a patient it can reflect the outcomes and the lack of transparency in the process where they have the knowledge and you are just left with the problems. But, in the pain clinic, it felt like there was a logic in the way that they assessed the total body and looked at the interactions of different body parts. This is especially important when there are different body parts involved or overlapping conditions that come under two different surgical specialties because it leads to a lack of clarity about where the leadership and ownership sits between the different specialties once you are an out-patient. Whereas in the pain clinic it is all assessed together and at the same time (almost like you are one person with all of the parts of your body connected!)  

They take a multifunctional approach

The other brilliant bit is that all of the different disciplines work together and talk to each other in the pain clinic. This is so different from life as an out-patient and even as an in-patient, when even when you try to get the physiotherapy and surgical side to align behind one treatment plan and talk with each other, one party always resists it (even if you promise to sign GDPR releases, volunteer to manage the phone call within your appointment and volunteer to step outside if there is something that they want to discuss without you present).

At the pain clinic they have a common goal to reduce and eliminate your pain, and they each bring their own specialist skills to this team goal. It feels like a sports team, with everyone rooting for each other and working hard to get a result. As a patient, you feel in good hands.

This team support is important. If there was one tip that I would give to Physiotherapists in the out-patient context it would be ‘don’t comment at all on any previous physio that the patient has had’. I have seen nine different physio’s through the path of my pain and universally in the first stage (when they ask you lots of questions about what has happened and what you have done before), every single physio has critiqued what the previous physio has done with very negative tones and criticism. This really does not help! We cannot turn time back and I have already decided to change physio to see you, so there is no need to justify why you will be better. It makes me (as the patient) feel vulnerable and scared, because it makes me wonder if I allowed the ‘wrong’ treatment to be given to me (even though there was no way that I could have had the knowledge to make this judgement). And when you have seen as many as me, you start to build a picture that there is no common view of best practice and that there may be a lot of snake-oil sales people in the physiotherapy profession who maybe have not kept up-to-date with best practice. I hope that this is not true, but is a clear impression that the criticism of others can generate.

So my advice for patients is to seek out a group who work together across functional boundaries with your wellbeing as a patient as their over-arching goal.

When should you go to a Pain Clinic?

There is not really a clear view on when to go to a pain clinic, and again you can get a lot of contradictory advice. The textbooks says that pain is considered to no longer be ‘acute’ and to have become ‘chronic’ after 3 months, although many GPs seem to operate on 6 months.

I also think that there is a lot of pressure on the resources of the pain clinic (and there is a really long waiting list for it – over 9 months in our area). My hunch is that this leads to a tendency to hold off from a referral to the pain clinic until it has been a very long and serious issue. If you have health insurance, there are also private pain clinics, although you will need to have a look at the terms of your policy to see whether this is covered and what the referral process is.

I would suggest that for the reasons above a pain clinic may be especially helpful if:

  • You have overlapping conditions that make you feel that you are falling through the gaps
  • You are not making any progress and need a different approach
  • You are reaching a point of despair

I wish you the very best of luck – you are not alone, and there is a brilliant team somewhere who can help you! Stay strong in order to find them and start to move forward.

Are you doing your physio exercises? If not – it is really worth working out why not!

Are you doing your physio exercises?

The actual exercises, with the frequency that you agreed?

The figures say that 80-90% of people do not do them. And I know of a physio who when injured admits that she does not do them! So what hope for the rest of us?

Injuries stop us from doing the things that we need and want to do. And the time and hassle of travelling to appointments is a further drain. So, what stops us from doing the exercises that can help us to get better?

Indeed, I was interested in a tweet from a US-based physio at the end of August where he wrote to the Twitter-sphere “I genuinely don’t understand. The activities I gave you help a lot with your symptoms, they take 12 minutes, but you “don’t have time” to do them? Can’t you get up 12 minutes earlier in the morning? Can’t you do them during all of those Netflix programs you tell me I should watch?!”  This led to some interesting points on Twitter, and made me want to write this blog post.

We tell ourselves that we do not have time. But is that really the reason? What is underpinning our procrastination and how can we find ways to overcome it?

Are we rebelling against the homework?

This is a moment to be honest with ourselves. When we know that it is doing the exercises consistently and correctly exercises, do we still want to rebel and not do them? Really?

Once we have given ourselves the pep talk to get on with it and ‘eat the frog’, how do we find the mechanisms to help us to do it each day? Some things that work include:

  • Scheduling and writing down the time in your diary to do the exercises each day
  • Setting an alarm on your phone for the time to do the exercises
  • Having a paper-tracker and star chart on the fridge or mirror as a reminder
  • Phone-based tracker of the exercises each day, with reminders
  • Giving yourself a reward for completing the exercises (eg a cup of your favourite tea)
  • Doing them early in the day, so that they do not hang over you
  • Being accountable to someone – letting them know that you have done the exercises each day
  • Letting the physio know that you really want to spend the first few minutes of each appointment reviewing how the exercises have been going, and then using these insights to progress the exercises after each appointment (you could even email an update to them before each appointment)
  • What else could work for you?….

Do we not believe in the exercises and the process?

Often we believe simple narratives and I sometimes think that for injuries, this is ‘the experts will fix me’. This is sadly not true and we need to replace it with a more realistic ‘my body needs daily help with the healing that is required, and I need to do these things every day as there are no short-cuts’.

As we think more deeply about this barrier, we may come to the conclusion that we do not believe in the current path – maybe we think that it is not yet the right diagnosis, or the right treatment plan, or the right person to work with. If these are the issues, then now is the time to talk these over with the physio, or go to see someone else for a second opinion.

I have often seen this loss of belief happen when an athlete has been seeing the same physio for over 6 weeks and is not seeing progress. I would suggest that the longer you leave making a change, the longer it will take to make a recovery – especially as I generally see the adherence to the exercises drop off with longer periods where there is no observed progress and no change in the exercises or approach. Obviously, the first stage is to talk over the concerns with the current physio, but a fresh pair of eyes generally provides a fresh perspective (and scarily frequently a completely different diagnosis and treatment approach!)

Or more simply, we may not understand why we are doing the same exercises, week after week. A good therapist will explain what the goal of the exercises is, and the test for seeing whether your body has made progress against that goal. This context is key – for instance after joint surgery doing the exercises through pain is key to stop scar tissue (which the body throws out in every direction) from forming across the movement planes of the joint and therefore limiting Range of Motion for good. Knowing that helps to push through the pain – but needs someone to explain it!

Do we fear the pain?

Many people do joke that the exercises are more painful than the injury. But really we should be in search of the ‘Goldilocks zone’ (as I blogged about in some detail last week) – enough to push and develop the under-active muscles or release the over-active muscles, but not putting ourselves so deep into the pain zone that we set the healing back, or push the body back into the ‘alert’ state that could lead to more guarding and defence.

In the event that the exercises are very painful, message your physio and when you next see them:

  • Get them to watch your form and be very specific on the exact movements and where exactly you should be feeling the benefits
  • Bring the number of reps and sets that you have managed to do (including when you have done them early in the day, when you are still relatively unfatigued) and discuss some more realistic targets.
  • Bear in mind that every single exercise can be regressed to make it easier – so get them to show you the regressions and agree what the triggers would be to move up through the various progressions.
  • Ask if there are ‘warm-up’ movements that you can do to get the releases and mobilisations before the exercise, in order to give your body the best chance of success.
  • Then stick with it and do not beat yourself up if you do not manage all of the sets and reps – every exercise that does not put you deep into the pain-zone will help!

Are we uncertain of what we are meant to be doing?

Many of the exercises are quite complex and when we are in pain we do not always listen and watch all of the form points. So if there are videos of the exercises – then watch them again and write down a note of the key points to remember in order to do the exercises correctly.

It may be embarrassing to have to admit that we are not really sure what we are meant to be doing – but it is in our benefit to clarify, so ask away! A good physio should be delighted that you are checking and clarifying. Do this at the start of the appointment, as if you only discuss the exercises in the last few minutes of the appointment, they are under time pressure and need to get you out of the door to get to their next patient.

If it is not any of these reasons, then what is it?

We owe it to our body to get to the bottom of why we are not doing the exercises, and then put in place. So keep taking a positive, inquisitive, collaborative and learning approach to your programme and your rehabilitation.

Good luck – and get those exercises done!

Back Pain? You really need to read this book before you do anything at all!

I challenge you to find better explanations and practical advice on back pain management anywhere!

Even though the pain can be so bad that you may not be sure that you can live through it, do not panic! Back pain affects 80% of UK adults at some stage in their lifetime (and usually in mid-life) and for the great majority of them, this passes within a week. For the 10% that it lingers more than a week, the scans and the words used by consultants can seem very scary.

I remember my Dad impressing on me the importance of avoiding spinal injury when I was a kid who loved climbing, abseiling and mountain biking. He was right that the back is a complex mix of bones, tissue, and nerves that drive everything, and the challenge is that the central nervous system is not very good at healing itself (medical experts are divided on what is possible vs impossible).

And back problems are not the end of your sport. 85% of male gymnasts, 80% of weightlifters, 69% of wrestlers, 58% of soccer players, 50% of tennis players and 30% of golfers have had back problems and the large majority of them have come back to their sport – albeit, for some of them, this has taken a little time.

Crucial advice for you before you go to any health professional!

This book ‘Back Mechanic’ by Stuart McGill claims to be ‘the secrets to a healthy spine your doctor isn’t telling you’. I would suggest that every athlete with back pain needs to get it and read it cover-to-cover twice before they take any action. It is very readable and contains truly excellent explanations, evidence-based plans, and case-studies from athletes where he has led their rehabilitation.

In the ‘Back Mechanic’ book, he explains why:

  • your pain may worsen after trying physiotherapy, especially with significant manipulation
  • why you can seem to be OK and then try to do something and be knocked out for 3 days straight
  • why it makes sense if you find walking faster is less painful than dawdling
  • why you may get told that the pain is in your head (which he completely refutes)
  • why just keeping a diary of your pain levels and painkillers is not enough
  • yoga and pilates may be recommended to you but may increase your pain
  • and many more questions answered!

A structured self-assessment and practical toolbox

The mid-section of the Back Mechanic book leads you through a highly diagnostic structured self-assessment of your back pain in static and dynamic movements.

From this, you can build up basic movement tools for simple, small, pain-free movements.

Then he moves into spine hygiene so that you can expand your pain-free abilities, with further sections on building a resilient back and restoring the hips, as well as specific conditions.

Will this help me avoid surgery?

There is a whole section on avoiding surgery, and the key decision points that will lead you to build an evidence base that suggests that you may not be able to move forward without surgery.

How to recover and trust your back

Many athletes who have come back from back problems say that one of the biggest challenges is regaining confidence in your spine. The second book – ‘Ultimate Back Fitness & Performance’ (which is more expensive and you may have to order from Canada or USA) gives a really excellent guide on building up from the end of the first book into using your back in performance situations but is a longer and harder read.

In summary

The message is – do not panic, don’t rush to the Doctor yet – read the ‘Back Mechanic” book and create a plan that you believe fits with your specific symptoms and responses to the static and dynamic tests in the book. It may take some time, but a good path to take given that 40% of people after surgery have ongoing pain and often end up having second and third spinal surgeries (each with considerably lower probability of successful outcomes).

Surgical skill or bedside manner?

We had a great debate over breakfast the other day. The question was –  if you had to choose, would you prefer a surgeon with great surgical skills and average bedside manner, or average surgical skills and great bedside manner? Of course, one hopes that you never have to make this choice, but it was a good debate!

My argument was that I wanted great surgical skills, given that I am unconscious at that point and once you are opened up they need to deal with whatever the situation actually turns out to be (which may be rather different from the best guesses on the scans). Having seen how incredibly thin and fine things like nerves are in many places, the fine-motor skills of dealing with this feel very important (and obviously in things like arthroscopy are one-step removed like a computer game!) I have to admit that I was only conscious once as I got wheeled into theatre (the other 6 times I was in a small ante-room with just the two anaesthetists) – but I was completely stunned to see 10 people and realised what a team leadership role the surgeon has!

But the counter-argument for the importance of bedside manner was a great one. The sad statistic is that many people continue to have pain after surgery (for instance, failed back surgery is said to run at about 40%, according to Penn Medical in the USA). So what you most need is to find a person who has the depth of skills to really understand what is going on in your body, and what interventions are most likely to help the situation. Therefore, someone who has a good ‘bedside manner’ to truly understand what is going on and whether surgery is a good option is what you most need. It can save you a lot of trauma and uncover a much better path.

The argument goes further. If you do have the surgery, the recovery phase is critical. Being able to explain what recovery and rehabilitation approach works best, and adaptations to make really increase the chance of recovery. Not to mention the softer factors, such as the level of trust and belief, which many would argue also play a key role in the mentality of the patient and therefore their biochemical make-up during the recovery phase.  

Supporting evidence that bedside manner may be much more important…

Having had four male surgeons, I was somewhat stunned that there was a statistically significant difference in the outcomes by the gender of the surgeon in this British Medical Journal comparison of postoperative outcomes amongst patients treated by male and female surgeons via a population-matched cohort study. It showed that fewer patients treated by female surgeons died, although there was no statistical difference in the proportion that were re-admitted to hospital or had complications within 30 days, compared to the matched group treated by male surgeons. If everything in your mind is screaming out that this cannot be true, then I will leave you to read all of the statistical analysis in the paper (including the interesting finding that the same pattern was true in emergency surgery, where the patient did not choose their surgeon):

https://www.bmj.com/content/359/bmj.j4366

But perhaps more interesting is the why’s, which the paper says need more study. But they already suggest that there is a gender difference in how male and female physicians practice medicine, such that it can affect patient outcomes.

They say that there are 4 core components of surgical practice:

  • Knowledge
  • Communication skills
  • Judgement and
  • Technical proficiency.

Obviously, post-surgery there are more people involved in the care so there are more factors too – and a previous study of beneficiaries of US Medicare that were treated by female general internists in hospital had lower rates of 30-day mortality and readmission than those treated by male internists (Tsugawa et al), which they attributed to female doctors being more likely to:

  • use a patient-centred approach and
  • to follow evidence-based guidelines

So what could this mean for your surgery?

Having never been in this surgical world before it was thrust upon me, I had no idea how to move forward. So here are a few tips that I would say now:

  • If you have Medical Insurance, ensure that it allows you access to the maximum pool of consultants (they generally operate in a number of different hospitals and each of them is self-employed, so worry about the surgeon access, not the hospitals)
  • Always try to find a surgeon who has worked with sports people.
  • Get recommendations from people in the know. There is no meaningful data that you can access on the outcomes by different surgeons, but nurses and people in the hospitals know it. Call on your network shamelessly to try to understand the real story. Take time over this – for all that you probably feel that you do not have time on your side in your situation, it is really worth doing lots and lots of investigation.
  • If you have to wait, it is a good sign. Whilst none of us want to wait when we are in pain, it is much better to be seen by a surgeon with a full plate and lots of patients, rather than the one with lots of gaps. Firstly, it is an indication of their reputation. And secondly, if they are busy, human nature suggests that they may be more balanced in whether surgery is the best option for you.
  • Don’t be afraid to ask for a second opinion. Many people say always go for a second opinion before surgery, and that surgeons should not be offended as they should also recognise that it is a big decision. I would say that if what they say doesn’t seem to fit, or you want to have more comfort before making a big decision like a second or third surgery, then a second opinion really helps. They say that the key is not to tell the second person what the previous diagnosis is so that you get a genuine fresh pair of eyes on the issue.
  • Go into the appointment with a list of questions and a second person in support. My experience is that almost all of the surgeons that I have met are extremely introverted and tend to say very little. Therefore it is down to you as the patient to elicit responses, and to keep asking the questions until you feel that you have understood the answer adequately. This is why I always take someone else to the appointments who also has the list of questions and understands what we are trying to understand from the appointment, as I have felt quite intimidated and not managed to get all of the responses that I was looking for when I was alone.
  • Always go to another medical specialist too. The old saying is that when you have a hammer in your hand, everything looks like a nail. So the surgeon is always likely to come back with the choice of wait and hope it gets better, or do surgery. Hence getting an alternate view of how another specialism would approach your issue is very useful – go to:
    • a good clinical physiotherapist (one who has done cadaver work, reviews scans, and works across a range of techniques that are not just manual therapy and strengthening exercises),
    • a chiropractor with a good track record (who again reviews scans and uses more approaches beyond the classic ‘twist and crunch’)
    • a sports rehabilitation specialist (who again reviews scans and does screening to present a treatment plan that shows clear milestones with review points for reassessment and case studies of where this has worked before with/without surgical intervention)

So I changed sides on the debate

Through the debate (and long after I had finished breakfast), I realised that the core of the issue for me is that I was falling into the trap that I think many of us fall into – the idea that surgery is a quick intervention that creates an instant fix.

Once I articulated that I believe that surgery is sometimes one step in the rehabilitation path, it becomes clear that the communication skills to make the right decisions with the patient are much more likely to get to a better outcome. And since communication is a two-way street, we as patients also need to do lots of work to make sure that we communicate and understand well through the process.

To go for surgery, or not to go for surgery

This is the moment of truth! Sometimes there is simply no choice and the only thing to do is try to manage the process so that your recovery can be the best that it can be (do talk about scar tissue with your surgeon!). But I have talked with people who have said that it is much harder when the case for surgery is not so clear cut, and the diagnosis or outcomes are less certain.

With the informed consent rules, it can be very difficult to get any definitive advice from the surgeon on what the likely probabilities are for different outcomes, and whether in their expert opinion it is likely to help or not.

You can feel very alone, in pain and probably having been suffering for a long time and feel that you have lost out on a lot of things. What should you do?

Many athletes have surgery and regret it

Many athletes end up saying that if they had known what it would be like in the years after surgery, they would not have had it. Don’t let that be you.

Some of the reasons may be that:

  • We are positive and believe that we can simply ‘will’ ourselves better, so when we listen to the range of outcomes and timings, we always believe that we will be in the best and fastest group – and maybe even tell ourselves that we can beat those odds too! This rarely happens. So brief the person who comes with you to listen carefully to all of the range of outcomes and probabilities.
  • We place high demands on our body, so even a slight level of dysfunction is noticeable and impacts our lives. We need to remind ourselves that almost everything has a workaround solution – you only need to watch the Paralympians to remind yourself of the power of this.
  • We may subscribe to the ‘instant-fix’ mentality of today’s modern world and forget that there is a lot of healing that takes a very long time. We are not like a bike or a machine, and will not be ready to go as soon as the mechanics are fixed – because there is too much soft tissue recovery, body trauma and system re-patterning to do.
  • We think that because we will be out of hospital in a few days, it will not take long. This is not at all true – whilst you will be home very quickly (and by the way you should plan ahead to ensure that you can cope in that difficult post-operative stage), the time for the body to heal is long. They will often cut through 9 different layers of tissue (even with keyhole) and each of these need to heal. Those with less blood supply heal slower, as they only get what they need more slowly. Whilst there are things that you can do that will make it go slower, there is little that you can do to make it go faster!

So what if you are facing the decision?

You have to find your own true-north on the right path forward… And all at a time when (for sure) your judgement is impaired as a consequence of the pain and frustration of your injury.

 Some tips that might help could be:

  • Take someone with you to the appointment to ensure that you get a well-balanced view of the probabilities of the range of outcomes. Having two of you helps to ask more questions and also listen and take notes in the appointment.
  • Ask about the surgery itself and understand the impact of the incisions and the consequences for the healing process. Often the scar tissue can be as much a factor as the ‘fix’ itself. And talking this through and understanding it can help with the decision (and indeed if you go ahead, with the choices around the exact surgical approach – for more on this read my blog on scar tissue)
  • Would you want to watch the surgery on YouTube?  Many people think that this is seriously squeamish and scary. But for others seeing it and understanding the different aspects enables an understanding of the level of trauma and recovery. And some watch it before going to see the surgeon, as it prompts different questions that they had not previously thought of. You need to think it through for yourself.
  • What is the sentiment on the internet about recovery from this surgery?  Obviously every patient is different and the internet will not tell you the answer for you. But if the prevailing sentiment is that it is a very long recovery, and not a full recovery – what are the common themes? And are there questions that you want to ask your Doctor about the specifics (without referring to the internet, as that is always how to upset Doctors!!)

What if you are not sure?

It is completely normal to come out of an appointment with the surgeon and to be really unsure of whether you want to go ahead with surgery.

If you wrote two lists on the same piece of paper – reasons, why to have the surgery and reasons why not – what would the balance of opinion suggest is the right answer? Is there any more information that would help to make it clearer? Is there anyone that you can talk over the list with to add more insight?

There are a couple of challenges to be aware of:

  • You can feel a sense of momentum that means that you feel pressure to go ahead (whether coming from the medical process, or from family & friends, or your own need to move forward). Resist it! This is a big decision and it is your body. So you need to be happy with the decision.
  • You may feel that there are no other options. This is never true.

So what are the other options?

There are a number of other options – some of which are below. Which one you go for probably depends on (i) how confident you are of the initial diagnosis of the issue, (ii) the level of improvement that you have seen (or not seen) through the current work of rehabilitating it and (iii) the levels of risk and length of predicted rehabilitation from the surgery.

  1. Get another opinion from another surgeon. You are absolutely entitled to this, and no-one should make you feel bad for asking this question.
  2. Continue rehabilitation with another physiotherapist (or whatever rehabilitation specialist you are seeing). There is a huge variation in the approaches that different people in the same profession take. And I would say that if you have been seeing them for more than a couple of months and are not making progress, then a change would be a good thing.
  3. Try a different approach. There are a lot of different therapy approaches, and when you spend a lot of time with clinicians you realise the levels of uncertainty – lots of intelligent guessing because they cannot see inside your body, and the level of variation in people. So for all that many can be very sniffy about ‘alternative’ therapies – these may be what your body will respond to.
  4. Give it some time.  This is a hard one – but can often work. So setting a time limit and truly resting and nurturing the injury by keeping away from activities that trigger it.

Good luck!

Only you can make this decision for your body – take your time and make sure that you feel  that you have explored the details and the options fully. It would be really sad to be a year or two down the line and regretting this decision.

How do I know that I am going to a good physiotherapist?

This was a question that I Googled over and over again, and had some pretty scary experiences. In the absence of finding any answers online, here is my view:

A physiotherapist is there to help make you better, so their first rule has to be DO NO HARM!

So – if at any stage- you feel  a sense of a lack of trust, or you feel that they are not listening to you, or if the way that they are manipulating you is not respecting your body, then I would immediately ask them to stop, sit up, step down from the table and say why you think that the appointment needs to stop there. And if they do not make you feel comfortable by talking through the treatment plan that they have for you and how it will make you better, then simpl pay, leave and never go back! I wish that I had thought through in advance of a couple of appointments how I would respond if I was unhappy with the way that I was being treated and what I would do – as in the moment you can feel frozen and under pressure to just take whatever you are being given.

When I first got referred to a physiotherapist by the consultant after reviewing my scans, I asked people who had been before what made a good one. It’s frustrating – whilst we can each get a very detailed understanding of what it might be like to eat out at a given restaurant or stay at a certain hotel based on ratings and reviews sites or specialist guides, there is no such thing for physiotherapists (or any of the medical profession)! Many have a couple of google reviews – usually all 5 stars and not more than two. My hunch is that these are done by friends, as in order to get a good google listing you need a couple of reviews. I never found a useful or insightful one on physiotherapists.

What is the difference between a physiotherapist, an osteopath and a chiropractor?

Google search shows that this is a very common question, but there are not many simple answers.   My answer is that it is all a spectrum in the ‘manual therapy’ part – ie the hands-on part (as against giving you exercises and watching you). Some physios will only give you exercises, and this would be a potential marker of a poor physio for me – a huge proportion of injuries will not get better without some manual therapy assistance and will certainly need some hands-on testing to understand areas of tightness. But within the manual therapy spectrum, physios seem to focus more on the muscular (and also sometimes fascia) connections, with osteopaths and chiropractors both focusing more on the nervous system, spinal involvement/alignment and into ligaments/tendons connections. My own experience is that the osteopathy end of the spectrum is more gentle and helpful in pain relief and relaxing issues associated with excessive tightness. Whilst the chiropractic end of the spectrum is more active and associated with actively addressing issues to get to ongoing alignment, including retraining muscles, ligaments and tendons.

The interesting part is that orthopaedic surgeons and GPs will all tend to send you to a physiotherapist and never one of the others. My understanding for the reason behind this is that physios have more years of academic training than the others, and are therefore held in higher esteem by the more traditional part of the medical establishment. But you may find that your body responds much better to the touch and skills of a different practitioner.

What are the signs that I have found a good physiotherapist?

Here is my top 10 list:

  1. They really listen to you describe the symptoms and pain sites, and ask good questions.
  2. They do a full body screening set of tests of range of movement, movement patterns and pain in all parts of your body, even if these are not the site of the injury or problem. And then as your treatment progresses, they keep going back to these tests and monitoring progress.
  3. They listen to your feedback on pain levels, and if you say that you cannot take any more, they stop. Especially if it is your first time having acupuncture or dry-needling. These should create a strong relaxation of the muscle, but some people do have a reaction to it – so if the needles continue to hurt they should take all of the needles out.
  4. They explain their thinking on the problem and their treatment plan – and answer questions if you have them. And in the case of the physio that I respected the most, I went to see him 3 times before he was ready to share his view of this, because he was building a more detailed picture and evaluating it before rushing in. One of the most useful questions I found at this point was to ask what a standard case of a XXX injury would look like a this many weeks after, and then to compare how I fitted against that.
  5. They are prepared to talk with the surgeon to build a connected treatment plan, based on all of the scans and expert judgement. This makes such a difference, as they are able to have a different conversation from the one that you can have with the surgeon. Plus, if you end up having multiple surgical interventions, it gives you as the patient the confidence that going to further surgery is the right plan, and the surgeon really does have the full picture.
  6. They welcome feedback from you (and ideally help you to structure it in a way that gives them the information that they need in a simple way) about how the pain levels and progress on the exercises has been since the last appointment
  7. They give a really clear protocol of what they want from you. Genuine misunderstandings are so rife: ‘take it easy’ can mean anything from no hard running, through to nothing more than a gentle walk! Likewise sitting might be really bad. Having a detailed protocol agreed of how you will approach general life, as well as the exercises, is really important.
  8. They layer their exercises from the simplest and least weight-bearing form of the exercise, building the complexity when your body can handle it. The most frustrating times for me have been with 2 different physios after different surgeries, when they said “oops, I chose a set of exercises that were just too advanced for you. We’ll have to try something else”. These in each case put me in a situation of being unable to move at all for days in one case and weeks/months in the other
  9. They demo exercises and then watch and correct your form on the exercises so that you can be confident of doing a perfect rep when you get home, and spot when to stop when you lose perfect form – rather than when you are crying with pain.
  10. They are prepared to say when you do not need to see them too! There are points when you continuing with the strengthening exercises and giving it time will be enough – and a good physio will say this, rather than continue to take your money!

The no pain, no gain view of physiotherapy is really unhelpful

Everyone who I spoke to before seeing a physio had the view that physiotherapy has to be painful for it to work – that the manual manipulation has to hurt to release problems and that exercises have to hurt to work. I totally refute this. I think that there is really good evidence that when a body is swimming in the chemical markers associated with pain and everything is contracting and tightening from the electrical stimulus of pain then the problems are increasing, not decreasing. This is not to say that like in sports massage sometimes pressure can help a muscle release and there may be times where a physio will warn you that there could be a little discomfort – but this should only be very short-term.

I regret having gone to see those physiotherapists whose exercises and interventions increased my pain.

As an athlete, I would steer away from hospital physiotherapists

Initially, we thought that going to the hospital physiotherapists would be the best plan straight after surgery, because we thought that they would be deep experts because they saw lots of cases of this specific surgery (given that they are at the hospital) and because we assumed that just out of surgery all patients would be in pretty much the same situation. This was a bad call. The physios that I saw seemed to always be surprised at the level of muscle strength that I had (even though after a year of problems, I had lost 15 kg of muscle mass on the body composition scales). As a consequence they regularly chose exercises that were way too difficult and caused problems. And to compound the issue, they then seemed to bounce into another set of parallel exercises with slightly different approaches that also caused more pain and problems.

So do you have to go to know?

I think that there is a certain amount that you can do before meeting a physio – you can ask specific questions to previous clients who recommend them, you can phone and ask the clinic how the physio approaches things, and you can ask to talk through your case on the phone or via email before meeting them – in order to understand whether you and they think that they can help to make you better.

But at the end of the day, some of it will unfold as the diagnosis and treatment unfolds. Keep asking yourself (and them!) the questions. If you are not improving, then you need to understand whether your time and money would be better spent somewhere else.

And finally…

As an athlete you may have built a mentality of pushing through pain to finish a race (or even a training set). Physio exercises are not like that. If they are hurting (not the good and comfy ache of activation, but jagged and unpleasant pain), then stop and do not do them again before talking with the physio. You may be rating yourself as the failure (as I was), but actually pushing over multiple days to try to complete just one set when it is the wrong exercise can cause a lot of damage. Listen to your body first, and the physiotherapist second.

Best of luck with finding a partner who can help you rehabilitate your body and get you back to the movement and activities that you love. You deserve that. There are many people out there, and many apply just the same approach to everyone who comes through the door. If that one happens to help you to improve – brilliant. But if you have to keep going, knocking on lots of different doors to find the person with the approach that fixes you – it is not a failure and it does not mean that your condition cannot be fixed.  Listening to your body, testing and monitoring progress on the key measures and finding the right person or people will move you forward, one step at a time. Keep at finding the right person, just as you would keep at finding the right coach or the right training approach. You have the resilience to do this – even when you are at your lowest ebb.

Your basic bodycare toolkit