Have you ever wondered what the difference between doctors and physiotherapists are?
Are you confused as to who you should see when you do get that pain or injury? “What’s the difference?” is often a hard question to answer, but in this post, I will help you understand the:
Qualifications of each profession
Scope of practice
Who you should see first, and
Questions that you should be asking your health professional
I have had my fair share of injuries before my physiotherapy degree. And so, I also have had experiences with multiple trips to the physiotherapist or doctor. Unfortunately, among the good experiences, I’ve also had terrible consultations with physiotherapists and doctors.
My two worst experiences include:
Getting told by my doctor, I should quit my sport because it would lead to long term damage
Feeling like I was getting milked like a cash cow by my physiotherapist who kept me coming in every week for ‘maintenance’ check-ups
Although these two experiences don’t highlight the bulk of medical and physiotherapy professionals, it is helpful to know what you should and shouldn’t expect when getting reviewed by each profession. In this post, I will highlight who may be more appropriate to see, and some useful questions to ask about your pain or injury.
Breaking down the professions
There are many different types of physiotherapists and doctors. Each of these specialities requires various forms of training and experience. These include:
Cardiorespiratory (heart and lung)
Neurological (brain)
Geriatrics (older adults)
Paediatrics (children)
Musculoskeletal (the muscles, joints, bones)
And many, many, MANY others specialities.
For this blog post, the ones that we mainly want to focus on are:
Private physiotherapists
General practitioners
These two practitioners are the ones you will most likely see when you have any initial onset of pain or injury.
Qualifications
Physiotherapists
Physiotherapy degrees can vary from 2 – 4 years depending on where you go to for physiotherapy. Physiotherapists are required to complete placements in private practices, hospitals or other services during this time. In which they are required to shadow or follow a qualified physiotherapist.
Physiotherapists operate under AHPRA (Australian Health Professional and Regulation Agency) and PBA (Physiotherapy Board of Australia). An additional affiliation that a majority of Australian physiotherapists have is the APA (Australian Physiotherapy Association).
In Australia, physiotherapists are classified as first contact practitioners and can see patients without a referral from a doctor. The physiotherapy system is different from many other countries which do require a doctor’s before the first consultation.
Some patients will still choose to see their GP’s first to get healthcare subsidies for their physiotherapy appoints.
General Practitioners
University degrees for doctors can take 4 – 6 years, depending on where you go to for university. Upon graduation, doctors usually undertake a residency/internship, which is a rotation as a doctor in a hospital for a minimum of 1 year. After which, they must take further vocational training in the form of:
FRACGP (Fellowship of Royal Australian College of General Practitioners) takes three years, or
FARCRRM (Fellowship of Australian College of Rural and Remote Medicine) takes four years
Doctors operate under AHPRA (Australian Health Professional and Regulation Agency) and MBA (Medical Board of Australia). An additional affiliation that a majority of Australian physiotherapists have is the APA (Australian Medical Association).
Scope of Practice
Scope of practice essentially defines the actions and limitations of a healthcare provider, which can vary depending on any additional training that they may have undertaken.
In a general practice, a doctor can:
Refer for MRI, X-ray or any other scans
Prescribe medication (pain medication especially)
Refer to a specialist for further review
Refer to allied health professionals, such as physiotherapist, podiatrist or exercise physiologist.
The roles and duties of physiotherapists are:
To perform a comprehensive subjective (verbal) and objective (hands-on) assessment
Provide treatment and rehabilitation plan in the form of:
Manual therapy or other hands-on modalities
Exercise prescription and rehabilitation program
Education of pain and injury
Understanding when to refer on to a doctor or other healthcare practitioner
Discounted Referrals
If you receive a referral from a Dr, you may be eligible for a Chronic Disease Management (CDM) plan. Under this management plan, a doctor must diagnose you with a “Chronic Medical Condition”, that is a condition “…present for six months or longer” before you are eligible for Medicare rebates for Allied Health Professionals.
Details of the rebates as follows:
Five total visits in a calendar year (Note: unused visits in previous years do not roll over into the new year. A new referral must be made at the start of every new year).
Currently, Medicare will only cover $54.60. If the physiotherapy practice charges more for their CDM clients, you may have to pay an out-of-pocket gap fee to cover the costs.
Must be referred from the Doctor to the eligible physiotherapist using a referral form
If you have acute pain or injury, then the first point of contact should be any healthcare practitioner that is available to your earliest needs. It doesn’t make sense if you have to wait two weeks for a physiotherapy consultation if the closest physiotherapist is booked out. Similarly, if your doctor is in a hectic period and is unable to meet with you, then the option to see a physiotherapist is also present.
For acute injuries, the recommendation would be to go to a physiotherapist. These generally settle within a few weeks, but having a physiotherapist to guide you and educate you on the path makes the journey much smoother.
If your pain or injury has been chronic and ongoing for an extended period, then referrals and communication should be made between both a physiotherapist and a general practitioner. This way, the two professions can create a treatment plan together that will best address the patient’s needs and help them improve.
Useful Questions to Ask Your Physiotherapist or Doctor
Below is a short infographic on the types of questions you should be asking your healthcare practitioner on your first consultation.
Conclusions
The world of healthcare practitioners is a complicated and hazy area. There are many crossovers between the roles and responsibilities of each profession.
Physiotherapists are your main contact for:
Thorough assessment and identification of pain areas
Treatment techniques to reduce pain and improve function
Exercise rehabilitation for long term outcomes and recovery
General practitioners assume the responsibility of:
Eliminating any major red flags; which include sending for investigations or referrals to specialist
Prescribing pain medication
Referral to allied health practitioners (including physiotherapists, podiatrists, dietitians or exercise physiologists)
So in the incident where you may have suffered an injury or have experienced some pain, go to whichever healthcare specialist is available in your area. In a future post, I will elaborate on what to look for in your healthcare worker and how to know whether you should be moving on!
Schedule an appointment now to see how our physiotherapists can help you!
Each one of these questions are so important, and for some, this might seem like a life sentence. But… What if I told you knee arthritis isn’t bad? Arthritis is a normal part of life, and an ageing process that each and every one of us have to go through as we age.
There are so many uncontrollable factors that influence the onset of arthritis, from:
Age
Gender
Fitness level, and
Previous injury (Gly-Jones et al., 2015)
It doesn’t seem so bad now does it?
We’ve all heard that arthritis is bad. That it’s this disastrous diagnosis spelling the end of our youth and that we have old and painful, arthritic joints. But the thing is, arthritis and pain are not mutually exclusive. What I mean is that: You can have a diagnosis of knee arthritis, and have pain… But you can also have a diagnosis of knee arthritis, and have no pain!
Confused yet?
The fact is that research supports the notion that osteoarthritic changes occurs in everyone. However, there are also individuals that have severe levels of joint arthritis, but are completely asymptomatic and have no pain (Dieppe & Lohmander, 2005).
Which means that arthritis DOES NOT equal pain. Please repeat that after me – Arthritis DOES NOT equal pain.
The good thing is, while we cannot fix your knee arthritis (because our medical and technological advancements aren’t at this stage), we can perform some simple actions and steps to relieve your pain. These are split into two main categories.
These techniques involve massaging or ‘trigger point release’ of the ‘tight’ musculature around the hip and knee joint, which may be involved in the tight sensation and painful feelings in these muscles. Fundamentally, massage does not change the underlying structures or physiology of muscles, nor does it make you any stronger, or place you in any position to decrease long-term outcomes by any means.
Regardless, they are still fantastic for pain relief. Trigger points and massaging of the common sensitive areas including: glute medius (side of your hip), glute max (your buttocks), your hamstring origin into the ischial tuberosity (the bony part of your bum) as well as the quadriceps (your thigh muscles).
As for duration and prescription – there are no strict guidelines as to how long you should spend on one specific area. The easiest way to approach this is:
Find a sore spot
Keep moving around on the sore spot until the tenderness decreases or disappears
Rinse and repeat
Be cautious of being over eager with massage, as you may find a bit more bruising the next day!
Part 2: Short-term pain relief – Passive stretching
Passive stretching is also a fantastic way to create some quick pain relief for tight structures and painful areas. However, while a long term stretching program may be able to increase flexibility or range, it does not increase the strength or stiffness of your muscles and tendons (Marshall, Cashman & Cheema, 2011). This may predispose the muscle or the individual to recurrent injury and may not provide any long term benefits.
Again, stretching is a fantastic adjunct or add-on to the next few steps, but should never be on its own. Some example stretches for the knee may include general quadriceps and hamstring stretches, glute med stretch (newspaper stretch), and calf stretching.
General prescriptions for stretching exercises generally vary around 20 – 30 second holds, for 2 – 3 sets of each stretch. I wouldn’t spend a lot of time stretching as there are other strategies and movements that can provide much greater benefits than stretching alone.
Part 3: Long-term pain management – Education
Understand that your pain is a multifaceted, complex machine. Simply attributing pain to the results shown on a scan is vastly underestimating the complexity of pain. Instead, we should be learning how to manage and understand the difference between “good” and “bad” pain.
We must understand that pain does not necessarily equate to structural damage within the knee. This is especially important as many are worried about further long-term damage when there is any onset of pain, especially with a diagnosis of knee arthritis. This can lead into negative habits and beliefs, and can have long-term consequences as a result.
A simple and easy way to understand this would be using “the pain cycle. “The cycle is destructive, and usually starts with pain, then immobility (decreased movement), atrophy (loss of muscle), decreased function which creates a predisposition for pain and the cycle starts again (Figure 1).
Figure 1: The pain-function cycle
Ultimately, our aim is to be able to intercept this pain cycle at one or multiple parts. Either through strengthening, encouraging movement and healthy practices, or – in extreme circumstances – the use of pain medication to offset the pain just enough that we can engage in exercises.
Part 4: Long-term pain management – Structured exercise program
Long-term improvement and prevention requires a structured exercise program aimed at targeting the specifically weak muscles of your lower limb. These exercise programs include strengthening of the glutes, quadriceps, hamstrings, calves and even your feet.
Exercise prescription is in itself a huge topic and one that I will save for a later blog post. However, general suggestions to improve lower limb strength and provide some basic strengthening for the lower limbs include: glute bridges, elevated glute bridges, calf raises as well as step ups.
Prescription for these can vary from 10 – 20 reps, 2 – 3 sets depending on your current fitness activity levels as well as your pain levels. If you are worried about rising or fluctuating pain levels, a set of rules that you can follow is, if your pain:
gets significantly worse during the activity
doesn’t settle after 10 minutes following stopping the exercise, or
is significantly worse the next day
Then STOP. You may have done too much, and will need to ramp it down and monitor your situation. Exercise prescription is a delicate balance between finding just enough exercise to help stimulate strengthening while also not performing too much that it stirs it up and makes it annoying unbearable to walk or move on.
Conclusion
Many individuals will have been plagued by knee pain or fear of knee osteoarthritis for years and years. Worse still, some individuals have been given the diagnosis of “knee arthritis” and were never given any actionable steps or solutions to easing pain and improving movement. The aim of this post is to highlight the fact that knee osteoarthritis is not a ‘death sentence,’ and we should not be overly worried about the ramifications brought about by scans and investigations and by even the words of some medical professionals.
Short-term treatments for pain may include massage, ‘self-myofascial release’, trigger points and stretches. However, if we are aiming for long-term improvement and prevention of pain in the knee, then understanding your pain is paramount and being able to provide a structured exercise program is key.
For more information, keep following our blogs for weekly posts.
Don’t hesitate, book in a consultation and talk to us!
If you could start moving again and get rid of your knee pain, how would that affect your life?
References
Dieppe, P. A., & Lohmander, L. S. (2005). Pathogenesis and management of pain in osteoarthritis. Lancet, 365, 965 – 73.
Glyn-Jones, S. Palmer, A. J. R., Agricola, R., Price, A. J., Vincent, T. L., Weinans, H., & Carr, A. J. (2015). Osteoarthritis. The Lancet, 386(9991),376 – 387.
Marshall, P. W. M., Cashman, A., & Cheema, B. S. (2011). A randomized controlled trial for the effect of passive stretching on measures of hamstrings extensibility, passive stiffness, strength, and stretch tolerance. Journal of Science and Medicine in Sport, 14(6), 535 – 540.
Usually, you’re not sure of what caused it, and it was only when you were getting ready to sleep that night that you thought “my back doesn’t feel quite right.” The next morning, you’ve woken up and your back feels terrible. You’re thinking:
“It hurts to roll out of bed”
“It hurts to bend over”
“It hurts to stand up straight”
“It hurts to sit down”
“It hurts if I move”
Part 1 – Back Pain Red Flags
First things first. Let’s clear some red flags. Red flags are signs and symptoms that, if present, need to be reviewed immediately and is a medical emergency. If you have any of the following signs and symptoms, it would be highly recommended that you go to the emergency room of your local hospital, or contact your local general practitioner.
Pain in your lower back that may travel down the back of the thigh, the calf and to your feet.
Frequent pins and needles, or numbness in both legs
Severe weakness in both legs
Faecal incontinence (i.e. sudden loss of the control of your poo)
Urinary retention (i.e. trouble urinating)
Gait / walking abnormalities
Numbness around the saddle region (i.e. the rectal and genital areas and the inner thighs)
These symptoms are synonymous with Cauda Equina Syndrome. If you already have a pre-existing history of these symptoms and have been cleared by a medical professional, then monitor for any changes to your normal signs and symptoms. Generally, if there are no red flags, then the individual is recommended to move as much as tolerated. It should be noted, that if pain does continue to worsen, or if the individual notices that their function is deteriorating quickly, then they should go to the emergency room to eliminate any sinister pathology.
Part 2 – What causes back pain?
My scan says I have a bulging disc and degeneration of my spine. My back is “out.”
Unfortunately, there is still a large disconnect between the current body of research and some health practitioners. As we now know, most investigation results from MRI, X-Ray or CT scan for your lower back doesn’t really tell you much. In fact, one study by Herzog et al. (2017) showed an individual who had 10 MRI’s within three weeks, and had results reported by 10 different radiologists! So what was the consensus? There was none. 49 different issues were reported, but 0 were reported in all 10 scans. Which shows that there is high variability in reported findings, even within the same patient.
Ultimately, scans can help exclude serious medical emergencies, but does not isolate your source of pain, and doesn’t really change your treatment strategy. An MRI of your lower back may be able to tell you what changes have happened to your back, but may not necessarily mean that it is the source of your pain/
This is important, because lower back pain – or even any musculoskeletal pain – is multifaceted, and there are several other variables that can affect your ability to recover from injury / pain and your pain levels. This includes your general health, factors such as sleep and nutrition, as well as previous injuries and fitness level.
Belief Systems
Perhaps understated, is your belief systems about your back pain and what back pain means to you. Unfortunately, it is not well addressed at times, and many patients and clients are always left thinking – My back will never be better and I have to be extremely careful about everything I do otherwise I’ll throw my back out and never be able to walk again. This couldn’t be further than the truth, and these negative thoughts and connotations are much more detrimental to your overall health and well being.
Timeline for Recovery Generally, the first 0 – 72 hours (3 days) will be the worst after the initial injury or flare-up. This is due to a normal acute inflammatory process that occurs with most injuries. Resolution of the majority of pain usually occurs in the first 4 – 6 weeks following injuries.
Following this time period, most individuals will be relatively pain-free. However, some will still have a lingering sensation, which they explain as “I can feel it’s there, but it doesn’t bother me.” Usually we can describe this sensation as the “last 5%”, and full recovery can sometimes still take weeks to months following injury and is dependent on a large plethora of other factors.
So in the meantime, what should you do?
Part 3 – General recommendations
With your newfound understanding of lower back pain, here are some quick tips to facilitate your recovery from any acute back pain, or flare-ups that you may experience.
Keep moving as much as possible. Motion is lotion.
Use pain relief strategies as needed. Whether that includes over the counter pain relief medication, heat packs or getting a massage.
Change your posture OFTEN.
Go for a walk.
Don’t worry!!! Your back will get better. Unfortunately, it does take time and a bit of effort, but eventually the pain will settle and your function will begin to return.
It really is that simple! Unfortunately, after experiencing your first bout of lower back pain, many individuals still look for that “magical cure” and “instant pain relief” strategies. Some individuals get suckered into paying for magical TENS (transcutaneous electrical nerve stimulation) and Ultrasound treatments (sounds extremely fancy, but really doesn’t have much scientific evidence to promote its use) or get round after round of massages, which provide fantastic short term relief, but very little for long-term changes.
With that being said, there are some certain movements and exercises that I do encourage doing as these can promote healthy movement through the spine and get you going just a little bit quicker!
Part 4 – 4 Simple Exercises to Relieve Your Back Pain
Here are four simple exercises, that may provide some pain relief and will encourage movement in the lower back. If these exercises are painful, then stop. Back pain is very individual to each person, so a blanket recommendation of exercises will not necessarily target YOUR back pain.
1. Knee rocks
Holding your knees, gently rock your knees backwards and forwards.
Continue this motion for 20 – 30 seconds while taking some deep breaths.
The same as knee rocks, but gentle rocking side to side.
2. Sitting side stretch
This stretches the quadratus lumborum (QL)
In a sitting position, reach one hand over your body.
When you feel the stretch in your side, take a deep breath through your chest.
You should feel your ribcage rise, and a large stretch through your side / back.
Take two to three deep breaths, then repeat on the other side.
3. McKenzie Extensions (Lumbar extension)
Lying on your stomach, prop yourself onto your forearms.
Slowly push your arms away. This should extend your lumbar spine.
Then, slowly lower yourself back into the starting position.
Repeat this motion 10 – 15 times or as needed.
STOP if it is painful. Do not push into the pain, instead stop just before the painful point.
4. Sitting Forward Stretch
Sitting in a chair, tuck your chin and bring your body down to the ground.
Slowly feeling each vertebrae move one at a time.
At the bottom position, take two to three deep breaths, and then slowly raise yourself back up.
STOP if it is painful. Do not push into the pain, instead stop just before the painful point.
Part 5 – Conclusion
Remember that your lower back pain will get better.
It does take some time and it becomes frustrating, as it really takes away your ability to do anything. However, you should keep moving as much as your pain allows you to, and don’t worry! If you’re worried about your lower back, or it hasn’t been getting better weeks after your initial injury, please contact a local health practitioner. Preferably a physiotherapist, as they can perform a detailed assessment and treatment plan that should be individualised to your case.
So what will a pain-free lower back let you do?
References
Herzog, R., Elgort, D. R., Flanders, A. E., & Moley, P. J. (2017). Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. Spine, J, 17(4), 554 – 561.
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There is plenty of car parks availabe throughout the complex.
