Edited with new photos and comment, September 2016
I have spent so long thinking of osteopathy as a profession twinned with chiropractic that physiotherapy has passed me by. I would never have thought to consider it as a career, because it seemed to be a dull occupation, lacking the depth, the sophistication, and the intellectual and clinical scope of osteopathy. In short, it sounded boring and limited. I was too clever and ambitious to just want to be told by a doctor to give the same old exercises to people with minor musculoskeletal problems. It used to irritate me when people thought that osteopathy was a bit like physiotherapy, and (to my embarrassment now) I remember I used to say “We’re a bit more like doctors, actually“. This is when I was a shiny new osteopathy student and thought that I was going to become a specialist holistic physician, like an alternative GP, and not the glorified massage therapist that I sometimes feel like now.
Physios – could they really be as useless as I thought?
In practice I rarely heard anything good about physios. (Yes I know a physio probably gets all our failures, just like we get theirs). Specific complaints from my patients were that the physio hardly touched them, or their massage was either too strong or too weak, and ineffectual in either case (evidently very different from my empathic and skilled hands-on approach!) They didn’t seem to engage with their patients. Patients got given exercises that made them worse, (lumbar extension often) and didn’t seem to have formed a great therapeutic relationship with their physio.
I assumed (with some envy) there was no pressure on the physio to make sure they got anyone better, because they were being paid by the NHS whether they got results or not. I also saw the odd acute patient who said the physio wouldn’t touch them because they were too acute, where I would happily step in and get them some instant pain relief or at least start the healing process. And nearly everyone seemed to get given ultrasound. My NCOR Research Hub had examined the evidence for ultrasound, and come up with pretty much zilch. So I didn’t have a high opinion of physios and didn’t think they actually helped anyone in pain; maybe they were just good at things like post-stroke rehab, or bullying people into getting out of bed and going for a walk?
I was in a minority on an Explain Pain course
I know I’m laying it on thick, but I’m honestly revealing my own ignorance and conceit. And I don’t think this is an uncommon judgement held by other osteopaths. Well, I think I was wrong in my judgement. I’ve changed my viewpoint so much so that I even found myself flattered to read leading twitter skeptic David Colquhoun describe at least one osteopath as “indistinguishable from the best physiotherapists”. And what led to this turnaround? I’ve actually looked at their books and courses, and spoken to them. Specifically I’ve just been on an Explain Pain course (led by David Butler) with one other osteopath, a couple of chiropractors, a reflexologist and dozens of physiotherapists. So on the basis of this one weekend, plus a little more exposure to physiotherapy (bloggers like Adam Meakins and Neil Maltby and Tom Goom, academics like Roger Kerry, and books like Louis Gifford’s Aches and Pains), I am in no position to make sweeping statements about the difference between physios and osteopaths, but I’m going to anyway.
Osteopaths and Physiotherapists: Compare and Contrast
The look of the people on the course – pretty similar
Yes they look like us: sensible footwear, not elaborately coiffed, relatively fit and very friendly. We probably have a few more of the brown rice brigade, and they probably have a few more in the protein shake camp, but it wasn’t that obvious here. The ratio of women to men on this course was something like 8:1. Yes, women vastly outnumbered the men, and this has often been the case on osteopathy courses. I suppose maybe I just go for female-friendly approaches like cranial and pain science. But I am still curious: where do you guys go for your CPD?
Their view of GPs and drugs – pretty similar
I picked up a resigned frustration amongst the crowd with the fact that doctors could pull rank but often had far less understanding than them of a patient’s condition. (In fact I got the impression that they not only feel superior to osteopaths, but also their own orthodox medical consultants). They have to contend with tricky political and hierarchical issues whereas we are outside the system. But just like us they don’t think GPs have much clue about MSK conditions, and just like us they are not great fans of a long term pharmaceutical solution. Certainly my naive idea that doctors diagnosed, then administered orders to physios who blindly and obediently carried them out without applying their own brain, is way off the mark. A couple of times I also noticed that there was a comical self-deprecation about being ‘just a humble physio’, in contrast to ego-inflated osteopaths, some of whom revel in self-appointed high status.
The value of palpation – Quite different
Palpation is highly valued in osteopathy. It’s an important form of nonverbal communciation. I love it: getting to know a patient through their tissues, building up that bank of palpatory experience, developing that confident and knowing touch that so impressed us when we were first year students. I remember vividly the contrast betweean a tutor’s intelligent touch and that of the students, who might have been dragging a wet flannel over our skin or prodding us clumsily with a blunt elbow. And I think we’re good at palpation. Unfortunately, however good you get at it, inter-reliability studies shows that palpation is basically diagnostically unreliable. And unreliable about large things, like which joint is restricted, or which muscle is tight, or which PSIS is higher. As for cranial inter-reliability, it’s a bit like standing two people in a field blindfolded, and asking them to agree on which way the wind’s blowing. But it’s still fundamental and essential to our profession because its value goes beyond diagnosis.
I don’t think it’s quite so important to physios. At one point on this course we had to palpate the ulnar nerve of the person sitting next to us. The speaker showed us exactly how to do it, as if we wouldn’t even know where to start. She even explained where the ulnar nerve went. It was palpation for beginners. On an osteopathy course that anatomical knowledge and palpatory ability would be assumed. But I bet that on an osteopathy course there would be a lot of outwardly displayed confidence, while inside a lot of insecurity. I hate that moment on courses when the pretend patient says “Are you sure you’re actually on my 12th rib?”. “No” is usually my answer. FYI neither my partner nor I were confident we had palpated the ulnar nerve, but it didn’t seem to matter so much to them. I suppose ability to palpate and manipulate are seen by many of us as the sign of a “good” osteopath. It’s different for them.
The holistic perspective – surprisingly similar
I suppose it’s obvious. We all treat patients. We are people, they are people. Whatever our particular style of treatment, or training, patients bring their lives and feelings into the room with them and this shapes the way we treat them. For some reason, though, I hadn’t expected physios to be quite so holistic in their approach. I thought that was our speciality. But no, they are quite familiar of course with the depressed patient, the manipulative patient, the patient who is like your best friend, the patient who really needs to just have a chat with you over a coffee. Oh yes they know all about the effect of the patient’s life, attitudes and beliefs on their condition. The course I was on was obviously tailored to that type of approach, but all these jobbing physios seemed quite familiar with the same territory that we are. And in a way, because they don’t have to keep proving their scientific credentials, they seem freer to embrace biopsychosocialism than we are because they’re not scared of being accused of being flaky. And to be totally honest, this course taught more structured, innovative and up to date methods of evaluating and using the psychosocial issues than I was ever taught or indeed use in practice. Time for an update in osteopathic education, I would say.
Research culture – they are way ahead on that one
Physiotherapy as a profession has been questioned and held up to scrutiny over the last two or three decades. They have developed a fantastic research and evidence culture in response. The Explain Pain course seems very intelligent, but could also look quite whacky and alternative, with its illustrations of bare-breasted women and brightly coloured post it notes, and user friendly terminology of “nuggets” and “dim sims”(- you’ll have to do the course or buy the book to understand this -) but along with the fun and different approach there is a great deal of solid science, and at the time of the course (2015) there had been at least sixteen randomized controlled trials already. This is for a pain education programme that held its first course in 2003. I bow down with respect. David Butler was able to say, with the authority of the scientific method, that there is “strong evidence that neuroscience education will decrease pain ratings, decrease perceived disability, and decrease pain catastrophisation”. And doesn’t that research give you confidence. I don’t have to convince patients it works, because some wonderful people involved in research have done all that hard work for me. Fantastic. You don’t have to BELIEVE it works, or CONVINCE your patients that it works, because a study has SHOWN it works. Ah, yes, that’s what research is for! And we can all use that research. Osteopaths just on the whole don’t seem used to using it. Fortunately, the Explain Pain crowd are not possessive or protective, and any of us can freely take advantage of their years of inspiration and perspiration by using their system in practice.
Work Environment – Bit different
One physio told me that last year she’d missed a ward round with an important consultant because she’d forgotten to move her clock forward an hour. In a flash, years of dispiriting and bleak hospital experiences were replaced by images of Sir Lancelot Spratt dancing in my head, and I realised I was still in thrall to the “Doctor in the House” idea of hospitals that I learnt from watching classic films as a kid. Wow – they get to go into hospitals and see lots of real conditions. How glamorous. How interesting! I also spoke to one physio who did a rehab job, doing hydrotherapy and taking patients for walks and educating them. Far from sounding boring, that actually sounds to me like quite a worthwhile way to spend the working day and do someone a great deal of good.
Some others I spoke to were in private practice just like me, but said there was plenty of work if you wanted it in the NHS. What a dream, I said, being able to treat people even if they couldn’t afford it, getting holiday pay, sick pay, workplace and equipment provided, job security. But no, the ones I spoke to said they would hate to have an NHS contract. “It’s easy money, but it’s not easy money”. They described it as under-resourced, with patients packed sardine-like to ridiculously short appointments: complex patients with poor prognoses – “the GP basically tells them they’re ruined then palms them off on us”, disengaged patients, patients not turning up, uncooperative patients, patients with poor understanding, antagonistic patients and on and on. The grass isn’t always greener.
Treatment content – A bit different
Yes they do refer to exercises a lot, rather than hands on treatment (strengthening and stretching type exercises, I mean, rather than just going out to do activities). And they do use ultrasound a lot, but there was plenty of laughter whenever it was referred to as the “ultrabullshit machine”. I think they might be more into strapping and taping and creams and lotions and machines and acupuncture than osteopaths. They manipulate (I’ve heard they call them “manips”), although not all of them do, and its popularity might be waning a little now. Craniosacral and visceral techniques are certainly on their radar. I attended a visceral course, run by a physiotherapist, which would make a devout skeptic apopletic. So we all use similar techniques, but I think we value and use manual techniques very much more than they do, and they use more gizmos and gadgets. The pain science crowd even refer to manual therapy “dinosaurs”, as if anyone who’s switched on these days knows that manual techniques are pointless. One physio said that they don’t touch patients at all any more, because it just makes people worse. (Not if you’re doing it right! we would say.)
Why, on the whole, they’re very much like us
But I felt surprisingly at home in a roomful of physios. I fitted in. I’m pleased that I trained as an osteopath, because it meant I had access to the exceptional quality of postgraduate training in palpation, manual technique and cranial, but yes I do envy them their culture of research and debate, their access to hospitals and their career choices. And these days I’m the one that tells people osteopathy is ” a bit like physio”.