If you have been lucky enough not to have injuries in the
past, you may not have any clue of who may be able to help you with your
injury. One of the most common questions is what is the difference between a
physiotherapist, chiropractor and osteopath? I also cover this in my previous
blog www.injuredathlete.co.uk/how-do-i-know-that-i-am-going-to-a-good-physiotherapist/
Chiropractors
generally focus on the integrity of your nervous system
The British Chiropractic Association www.chiropractic-uk.co.uk says that chiropractors specialise in back
pain, neck pain and sports aches & pains:
“Chiropractors specialise in assessing, diagnosing and
managing conditions of the spine. They are highly-trained in finding the cause
of pain in the spine. In the UK they undergo a minimum of four years’ full-time
training. Importantly, chiropractors are regulated by law and must work within
strict professional and ethical boundaries. Before starting treatment, a
chiropractor will do a full assessment. This will involve taking details about
your condition, current health and medical history, and performing a physical examination.
Sometimes it may be necessary to refer you for other tests, such as X-rays, MRI
scans or blood tests. It is important for your chiropractor to gather as much
information about your back pain as possible so that the most precise diagnosis
can be made.
“Your chiropractor will then explain what is wrong, what can
be done and what you can expect from chiropractic treatment.”
How do I know that it
is nerve pain?
Of course, it is really hard to work out the cause of pain.
Nerve pain accounts for much of the pain that goes all of the way down the leg
(sciatica is a classic of this, but there are also other nerves that take
different paths down the leg). The words that people usually use for nerve pain
include words like prickling, tingling, burning plus sometimes stabbing,
spasming and cramping. At their worst they can literally take your breath away
and leave you unable to speak, stand or so anything.
Many people fear that
chiropractors will be very physical and involve lots of popping
There is a range of chiropractic techniques. Some use just
their hands for manipulation and other techniques use tools that can help to
rebalance the tightness of muscles, tendons, ligaments etc and enable the
rebalancing and correct alignment of the spine and therefore the body, both at
rest and in movement.
The short, sharp movement with popping for spinal alignment
is just one technique, and if this is not what you want, then talk with your
chiropractor. For more advice, this link is worth a read:
When you are in pain,
there is lots of compensating
The bad news about compensating behaviours is that you can
start to get pain in parts of your body that were not involved in the injury.
For example, most injuries are more on one side than the other. This means that
you are not evenly balanced across the two sides, but the brain does not
tolerate the eyes not being level at all times. So the top of the spine often
takes a compensating role, and this can lead to issues in your head and neck,
as well as the site of the injury.
More runners’
injuries are related to nervous system issues than you might think
Joe Uhan has written a series of very useful posts on how
often ongoing injuries in runners are related to nervous system issues. You
could start by reading his blog on the I Run Far website for trail running and
ultra-running https://www.irunfar.com/2017/08/six-signs-that-your-running-injury-is-nerve-pain.html
and then follow the related links into his related blogs on treating nerve pain
in runners.
But if you are needing help with the healing process, cranial-osteopathy may be a technique that helps reduce your pain. And chiropractic interventions may help to find that ‘reset’ button to get everything working together again to move correctly without pain. Many athletes swear by the support chiropractors have given to get them back on-track.
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:
They really listen to you describe the symptoms and pain sites, and ask good questions.
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.
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.
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.
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.
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
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.
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
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.
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.
