Bridging the Gap: Knowledge and Personal Practice

Physiotherapy is a Medical Science

Physiotherapy is a relatively young profession compared to globally established professions such as law, accounting, medicine, and engineering⁽⁶⁾. Yet physiotherapy requires substantial academic insight into human physiology, anatomy, and biomechanics^(7-9). It also requires proficient communication skills and the ability to identify psychological and social risk factors for injury and illness^(8-10). Furthermore, they must complete at least four years of academic and clinical training, equivalent to a university honors degree⁽³⁾.

Physiotherapists are licensed experts of physical rehabilitation, meaning they have the unique role of diagnosing and treating physical injuries at all stages of the injury, while also assisting with injury prevention and recovery from exercise^{(3, 7, 11)}. As physiotherapists assist at all stages of an injury, they work in various settings. For example, physiotherapy is needed at hospitals, schools (special needs and sports-oriented), nursing homes, factories, armed forces, sports teams, and the general office environment, amongst many others⁽¹¹⁾.

Since the 1900s, physiotherapy has adopted scientific reasoning by considering the body as a machine⁽⁸⁾. Indeed, the profession has since progressed exceedingly in its scientific understanding of physical rehabilitation, and now considers patients as complicated human beings, affected by numerous biopsychosocial factors⁽¹¹⁾. Nevertheless, physiotherapy services must be delivered scientifically, as scientific reasoning underpins the profession.

A semi-profession?

While physiotherapy might not be a so-called “blue-collar” profession, it is not quite a “white-collar” profession either⁽⁶⁾. Unlike traditional “white-collar” and “blue-collar” professions, physiotherapy was initially created as a career for middle-class women⁽⁶⁾. Therefore, although the academic and clinical training of physiotherapy rivals that of traditional “white-collar” professions, physiotherapy inherently lacks esteem in society, leading some authors to consider the profession a “semi-profession”⁽⁶⁾.

Yet physiotherapy is the main form of conservative treatment for many major orthopedic conditions, such as disc herniations, neuropraxias, radiculopathies, cruciate ligament tears, and Achilles tendon ruptures, to name a few⁽¹²⁾. Moreover, there is compounding evidence for the need for exercise therapy alongside cancer treatment⁽¹³⁾. In one meta-analysis, strength training reduced cancer fatigue (a unique fatigue inflicted upon patients with cancer) and improved quality of life (QoL)⁽¹³⁾. Physiotherapists are also essential to helping decrease the risk and spread of non-communicable diseases by accurately prescribing and promoting lifestyle changes, such as exercise^{(1, 3, 11)}. Therefore, they have a significant role in physical rehabilitation and health promotion⁽¹⁾. Thus, the role of physiotherapy in society is indispensable^{(1, 3, 7, 12)}.

Return to play

The process of return to play (RTP) following injury remains a controversial topic in sports medicine, with no universally agreed-upon guidelines for when it is safe to resume sport or activity^(14,15). However, certain injuries, such as concussion, have strict and clearly defined RTP criteria, which are validated by multiple international sports organizations such as World Rugby, FIFA, and ICC^(16-18). In recent years, international sports organizations have taken steps when managing concussions due to the severe physical and mental consequences of repeated head injuries^(16-18). However, clinicians may be more nuanced with their RTP guidelines for other, more common musculoskeletal injuries, despite the risk of lifelong disability^{(19, 20)}. For example, cricketers who had played sport injured had impaired QoL, increased risk of osteoarthritis, and persistent joint pain, when compared to cricketers who didn’t play with injury⁽¹⁹⁾.

As injuries require specific exercise and rehabilitation, athletes expect that physiotherapists are well-informed about injuries and have a clear understanding of how to treat them⁽⁹⁾. Athletes expect physiotherapists to provide detailed information about the rehabilitation process and what to expect with an injury⁽⁹⁾. Therefore, physiotherapists must be highly knowledgeable about exercise, to ensure exercise prescription is accurate and to limit the incidence of undue disability⁽²¹⁾.

Athlete Compliance

There is evidence in the literature that patients default on their rehabilitation, with one South African study demonstrating that a third of its participants default on their prescribed concussion rehabilitation⁽²²⁾. This appears to be multi-factorial, with the authors of this study blaming peer pressure and intrinsic motives for the students’ defaulting on their rehabilitation programs⁽²²⁾. However, this same study demonstrated a lack of education about concussion amongst many high school and professional rugby players from various countries⁽²²⁾. It is the physiotherapist’s role to educate the patient about their injury, including the importance and rationale for rehabilitation. It is unclear whether patients default on their rehabilitation because of a lack of concern or a lack of education⁽²²⁾.

Higher adherence to prescribed physiotherapy provides superior outcomes in the treatment of injuries⁽²³⁾. Nevertheless, adherence to rehabilitation is deeply subjective and dependent on a variety of biopsychosocial factors, including physical and mental health, environment, socio-economic status, health and lifestyle behaviors, intrinsic and social beliefs, to name a few⁽²⁴⁾. However, there is evidence that physiotherapists insufficiently educate patients about their injuries^{(9, 23)}. Interestingly, various researchers propose that many physiotherapists do not regularly participate in vigorous exercise, and therefore lack a deep understanding and empathy for exercise, and thus, insufficiently educate their patients about prescribed exercise^{(1, 3, 4)}.

Leading by Example

Regardless of the branch, physiotherapists need to have a keen interest in exercise to prescribe it accurately. Ironically, two South African studies investigating how often student physiotherapists exercise show that they are not meeting the World Health Organization (WHO)-recommended exercise dose^{(1, 3)}. As illustrated by scientists from the University of Cape Town (UCT), a large portion of South African student physiotherapists do not participate in sufficient exercise, with only a third of students in this study regularly participating in vigorous activity (see Figure 2⁽³⁾). Furthermore, there is increasing evidence from the UK that physiotherapists do not engage in sufficient exercise themselves and very often do not follow international guidelines for exercise prescription^{(4, 5)}. In a recent study published in the British Medical Journal (BMJ), most physiotherapists in the UK were found to engage in very little exercise, have limited knowledge of exercise, and insufficiently prescribe it (see Figure 3⁽⁴⁾).

These findings are concerning, as practitioners prescribing behavioral changes should engage in the required behavior to induce change in their patients⁽³⁾. The findings of this UCT study are further substantiated by psychology studies on human decision-making behavior, which show that people are more likely to take advice from those with a proven track record and validated experience in the topic⁽²⁵⁾. This suggests that effective physiotherapists are not only enthusiastic about exercise but also have advanced experience with it⁽²⁵⁾. Moreover, there may well be a link between suboptimal exercise prescription and practitioners who engage in insufficient exercise⁽⁴⁾. If exercise is suboptimally prescribed, treatment is likely to fail^{(1, 2, 4)}.

Clinical Implications

To help curb sub-optimal exercise prescription, clinicians need clear RTP guidelines for all major neuromusculoskeletal injuries. By establishing best-practice guidelines for assessments and treatments, the physiotherapy may ensure more accurate care for its patients.

Additionally, exercise training and theoretical and practical exercise modules should be mandated in undergraduate physiotherapy degrees⁽¹⁾. Theoretical and practical exercise modules should be foundational components of university physiotherapy training.

Conclusion

Physiotherapy is vital to society; however, exercise is vital to physiotherapy. Physiotherapists need to have comprehensive knowledge of exercise, and that can only be achieved if they themselves have a comprehensive history of participation in exercise. They must adequately fulfill their role of prescribing exercise in the presence of injury to ensure the best outcomes for their patients.

References