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Clinical Review
What happens at the
physiotherapy clinic?
Richard Shortall explains what
exactly physiotherapists do and
which patients benefit most from
being referred by their GP
Have you ever wondered what goes on when your patient
attends a physiotherapist for treatment? By the end of this
short piece, I want readers to have a better understanding
of what we do, why we do it and which patients benefit from
physiotherapy and how.
I specialise in neuromusculoskeletal (NMS) physiotherapy – previously called ‘orthopaedic physiotherapy’, a term
now usually reserved for my hospital-based orthopaedic
colleagues. Some of the most valuable and educational
experiences I have had in my career are those in which
I had the opportunity to work in close collaboration with
my medical and surgical colleagues. Unfortunately, clinicians are usually sequestered from each other and so these
enriching interchanges happen all too rarely.
While it is difficult for us to work simultaneously in the
same room, with patients, it is desirable to work in concert
to achieve better outcomes for patients. Chronic aches and
pains and recurrent musculoskeletal complaints, for example, can be very frustrating for GPs.
But more and more doctors are achieving beneficial
outcomes for their patients by prescribing successful physiotherapy treatment. But what happens to your patient at
the physiotherapy clinic – especially at that all important
first visit?
Inform – explain – reassure – ‘reduce the threat’
While we have known for some time that patients benefit
from being better informed,1-6 patients are often dissatisfied with the information they receive7-9 and many doctors
simply do not have the time to provide as much information
and education as they would like.10 Physiotherapists are fortunate in that they have more time to do this than a doctor
in a busy general practice.
Patients are often confused about their ‘injury’, misinformed by the media and the internet and frightened by
the horror stories enthusiastically retold by friends and
family.11 Many are anxious or even alarmed by their diagnosis or their MRI results, which seem to suggest their body
is ‘disintegrating’ (a word patients frequently substitute for
‘degenerating’).
Pain scientists tell us that the more a patient perceives
the injury as a ‘threat’ to them (as an organism), the
more pain they are likely to experience, and that negative
46 FORUM December 2012
thoughts and emotions encourage fear avoidance behaviour
and promote disability.12 These patients are ideal for physiotherapy intervention.
Even if treatment consists solely of education about the
diagnosis, the pathology and the prognosis and teaching
simple self-management strategies to avoid recurrence
and chronicity, it is clinically valuable: they can benefit
from this information for the rest of their lives. Simple selfmanagement strategies include protection of injured tissue
and home programmes for strengthening or stretching of
dysfunctional muscles.
Assess – diagnose – hypothesise – hone
The physiotherapist assesses the patient during the first
visit. During the assessment a comprehensive history is
taken, followed by a detailed physical examination. Assessment is aimed at identifying patients’ physical impairments
and functional deficits and finding their causes: treatment
aims to address the causes.
Common impairments include: poor alignment (posture);
weak, tight, overactive, atrophied or injured muscles; irritated nerves and hypersensitive regions; problems doing
a movement or task; poor balance; stiff joints; instability
(‘giving way’, laxity) and even deleterious beliefs, cognitions
and behaviours. The most common complaint is pain.
The physiotherapist uses this information (particularly the
list of impairments) to develop a ‘best-fit’ hypothesis for the
cause of the patient’s problem and this in turn provides a
rational framework for physiotherapy treatment.
Assessments of experienced clinicians are more robust
because they usually feature tests and procedures spe-
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Generalised assessment findings with sample treatments
Impairment
Consequence
Treatment
Physiotherapist’s task, identify:
Pain
Fear – avoidance, disturbed
sleep, diminished socialisation,
compromised function
• ‘Reduce the Threat’ – explain problem accurately without recourse to
potentially emotive language
• Support, brace, tape, ice, advice
Cause of pain – giving considering to possible organic and
psychosocial causes
Tight muscles
Loss of ROM or abnormal
biomechanics
• Stretching
• Manual therapy techniques
• Home programme
Reason for tight muscles
Stiff joints
Loss of ROM, pain, impaired
function
Joint mobilisation, home ‘stretching’
programme
Cause of stiff joints
Irritated neural
tissue
Restricted motion, avoiding
activities and work positions,
sleep disturbance
Explanation, manual therapy, home
programme
Source of nerve irritation
Weak muscles
Loss of function, soft-tissue
‘overuse’
Specific strengthening exercises, home Explanation for weakness:
exercise programme
neural, myotomal, inhibition,
disuse, trigger point?
Sensitive/tender
regions
Abnormal movement patterns
(avoidance)
• Explain hypersensitivity and
neuroplasticity
• Desensitisation programme
Cause of sensitivity; inflammatory, neural, central
sensitisation?
‘At-risk’ tissue
Antalgic gait (or other abnormal
movement patterns)
Splint, tape, brace, support, protect
Odds of re-injury
Adherent tissue
Restricted movement patterns
• Manual therapy
• Teach exercises
• Home programme
Extent and cause of adhesion
Poor balance/
co-ordination
Inefficient/unsafe movement
patterns
cifically aimed at falsifying or at least stressing emerging
causative hypotheses. As in other clinical fields, assessment, hypothesis generation, exercise prescription and
treatment are increasingly evidence-informed.
While it is a relatively simple matter to identify the proximate cause of many NMS conditions – the patient may
have fallen, lifted a heavy load, done unaccustomed physical exercise or been the victim of a physical assault – other
patients present months or even years after the natural
‘healing time’ for their injury has passed.
The physiotherapist tries to find out why, for these particular patients, nature has not taken its course and resolved
the problem: ultimate causes are sought. This is why a
patient, sent to a physiotherapist with, for example ‘wrist
pain’ or ‘de Quervain’s tenosynovitis’, may have treatment
solely directed at the cervical spine, while another with
‘Trochanteric bursitis’ or ‘ITB syndrome’ may be successfully treated with biomechanical foot orthoses or targeted
strengthening exercises for the hip lateral rotators, without having specific treatment for the symptom-generating
tissue. The medical diagnosis is not being ignored: the
putative ultimate cause of symptoms is being addressed.
While specific interventions, such as joint manipulation,
dry needling, stretching, strengthening and ‘stabilisation’
exercises, support bracing, explanation and education,
are aimed at the cause of patients’ impairments and func-
Cause of poor balance/
co-ordination
tional deficits, treatments also serve as empirical tests of
the therapist’s hypothesis. Changes in a patient’s condition
can be seen very soon (seconds to hours) after treatment
and the causative hypothesis, empirically supported (or
undermined) by these responses, is honed accordingly. In
this dynamic feedback process, subsequent treatments are
directed by improved versions of the causative hypothesis,
versions that the physiotherapist has refined after observing
responses to treatment. Hypotheses that are strongly undermined by outcomes are discarded – sometimes a follow-up
assessment is needed.
A simplified hypothesis-honing process might look like
this: A patient presents with restricted motion in the shoulder region and pain of insidious onset. The physiotherapist
finds tenderness and restricted accessory motion (‘jointplay’) in the cervical spine.
A possible initial hypothesis that the neck dysfunction is
causing the shoulder problem and that the patient’s pain
is referred pain, is tested by treating the neck. If manual
therapy to the neck improves cervical ‘joint-play’ but the
pain and dysfunction remains unchanged, the hypothesis
may need re-drafting.
Who can benefit from physiotherapy?
Injured patients are the most obvious category who can
benefit from physiotherapy, eg. fracture, dislocation, contusion, sprain, strain or joint derangement. Acutely injured
FORUM December 2012 47
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Clinical Review
Patients likely to
benefit from physiotherapy
Among those who are likely to benefit from physiotherapy
are:
• Patients who need to be educated about their condition
or injury, their imaging reports, diagnosis or self-management strategies
• Patients who present to the doctor’s clinic with the same
or related injuries time after time; problems such as
recurrent or chronic lateral epicondalgia, neck/shoulder
pain, bursitis, pseudo-radiculopathy
• Patients complaining of ‘stiffness’, ‘weakness’, ‘loss of
strength’, ‘loss of endurance’, deterioration of movement
or diminished function with musculoskeletal pain, headache, TMJ pain; nerve irritation, spinal problems (strain/
sprain/dysfunction), especially if it cannot be isolated to
a single structure
• Patients who are currently, recently, chronically or recurrently injured by overuse or postural mechanisms
• Patient who have had a significant injury in the past
(recent or distant) and are therefore likely to have an
ongoing muscle or joint dysfunction, proprioceptive loss
and functional deficit that have not been addressed
• Patients who have had surgery – especially orthopaedic
surgery. Muscle dysfunctions and proprioceptive loss
leave patients vulnerable to injury and are not selfcorrecting over time
• Patients with difficult presentations (eg. extrasegmental
referral, ‘bizarre or roaming symptoms’ and atypical
symptoms – these often have easily identifiable impairments and functional deficits)
• Patients with NMS conditions resistant to standard medical interventions (eg. anti-inflammatories, analgesia).
patients benefit from not only early treatment and assessment, but re-assurance, explanation, advice and education
about self-management and prevention of recurrence and
chronicity.
Patients should not wait until pain, swelling or incapacity ‘settle down’ before consulting a physiotherapist. Many
patients wait in vain, sometimes for years, for problems like
these to settle down only to finally present with very chal-
48 FORUM December 2012
lenging chronic conditions or widespread pain.
One cannot assume that impairment of muscle function spontaneously resolves once the initial pain or injury
is gone. Physiotherapists routinely encounter patients with
functionally significant muscle dysfunctions years after initial injuries are ‘healed’.
Human beings display a bewildering repertoire of compensations and thus general activity does not address
muscle and joint dysfunctions which can persist despite
an apparent return to ‘normal’ activity, range of motion or
even ‘strength’.
Richard Shortall is a physiotherapist based in Dublin
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