Hvorfor er manuellterapi/fysioterapi en sovende gigant?

Sitatet hvor fysioterapi blir omtalt som en sovende gigant i behandling av smertefulle tilstander kommer fra boka Pain: A Textbook for Therapists, publisert i 2002. Forordet i denne boka er skrevet av Patrick Wall rett før han døde i 2001. Patrick Wall revolusjonerte smertefeltet i hans levetid.

Originalsitatet jeg fritt tolker på bloggen her er:

«I am convinced that physiotherapy and occupational therapy are sleeping giants.»

Under følger forordet som jeg må gi en stor hattip til Diane Jacobs for å ha linket til på SoMe i 2009 🙂

«I am convinced that physiotherapy and occupational therapy are sleeping giants. This book is one of those welcome signs that the long sleep is over. For well over 2000 years classical physiotherapy was practised in every culture as a folk tradition. It was all there: heat, cold, massage, manipulation, acupuncture, aromatherapy, etc. Since it was deeply embedded in every society and therefore attracted little intellectual attention, it was simply accepted as an empirical fact of life without the mechanisms being questioned. Occupational therapy is a newer profession: it emerged in response to the many veterans of the 20th century world wars who returned home traumatized, often disabled and in need of occupational rehabilitation. Still, a central tenet of occupational therapy, that humans have a need for meaningful occupation to cope and live with health problems, has been with us for centuries.

In the 18th century, a disaster hit the subsequent development of rehabilitative professions: it was the Age of Reason and the time when academic medicine was developing. This powerful and hugely successful movement was based on two essentials: diagnosis based on pathology and on an obsessional search for cures based on rational therapy. Rehabilitation interventions lost out on both counts. The conditions treated often had a vague or non-existent pathology. Only the wildest who exhibited both charisma and the confidence of the charlatan claimed to effect permanent cure. The vast honest majority were proud of the ability to ameliorate the condition. Physiotherapists and occupational therapists were not the only professionals to be demoted by academic medicine. Palliative care, for example, had to wait for two centuries before regaining respectability, since it made no claim to cure. It climbed back to acceptance, once ‘proper’ doctors said, ‘there is nothing more to be done’.

Physiotherapy and occupational therapy survived at the very bottom of the academic hierarchy. From the more-honest doctors, physiotherapists won a certain respect because it was clear that they were indeed helping some patients. For the less-honest doctors, physiotherapy represented a polite dumping ground for patients who had been labelled as unfit for appropriate rational medical or surgical therapy. Occupational therapy was considered useful to keep patients busy and diverted from their problems.

In the spirit of the times in the twentieth century, there was a partial move away from the traditional apprenticeship in which skills were taught by a senior physiotherapist who looked back with cosy pride to the traditional art. Bright younger physiotherapists and occupational therapists began to seek education to learn the rationale for what they were doing.

But what education? The answer seemed to be obvious: an abbreviated and dumbed-down version of what medical students were taught. This was a particularly unfortunate approach to the crucial subject of pain. Classical medicine had deliberately downgraded the study of symptoms, such as pain. Symptoms were regarded as no more than signposts that should not direct exploration of the only true road which led from diagnosis to cure. The phrase ‘symptomatic medicine’ became offensive, designating a low-grade practice that failed to face the deep professional problem of fundamental cure. This attitude condemned physiotherapists and occupational therapists to stick to the bottom of the academic ladder. It is symbolic that that physiotherapy and occupational therapy departments are often found in the windowless basement of most hospitals.

Medical school gave short shrift to an explanation of symptoms. Pain was inevitably caused by the pressure of damaged tissue which excited special nociceptor nerve fibres. These fibres fed a system in the central nervous system which was hard wired and modality dedicated, which triggered activity in a specific pain centre. This plan was completely accepted, and naturally directed the attention of the new academic physiotherapy entirely to the periphery. This resulted in a gaudy flowering of plausible but unlisted hypotheses to explain the aim and effect of the therapy. Since it was accepted that pain could be produced only by clearly pathological tissue and since physiotherapy was directed at that tissue, the hypotheses proposed tissue changes. Changes of arterial or venous or lymphatic flow, speeding the resolution of the inflammation by heating or cooling, release of trapped nerves by breaking adhesions or readjusting bones, relaxation of cramped muscles all make up the canon of courses in the intent and rationale of physiotherapy.

Four new areas of discovery have moved the emphasis from an entirely peripheral explanation for the source of pain and have opened up the field of debate to include the central nervous system. The first was the recognition of the crucial significance of referred pain. The site of the perceived pain and target therapy is not necessarily the site of causative pathology. For example, angina is undoubtedly caused by ischaemia in the heart and yet the arm may be the area of the troublesome disorders in spite of the fact that no pathology resides in the arm. The recognition of the phenomenon forced a conclusion that convergences occur within the central nervous system. Therapy may be directed successfully at both the primary and the secondary site.

Next, it was shown that widespread tenderness and muscle contraction associated with the peripheral damage can be caused by a secondary excitability in the spinal cord. This shows that the use of crippling pain may migrate from its original area in the periphery into central areas. This is one of the clear signs that the pain mechanism is not rigid, dedicated and hard-wired, but plastic and changes with time.

The third change was the discovery that the pain producing messages reaching the brain are controlled descending symptoms originating in the brain. This opened the entire field to psychology, with the understanding that pain is not simply a mechanical response to the presence of tissue damage but is affected by the mood and the attitude of the one who suffers. The most obvious example is the role of attention, which must be directed to that area, if pain is to be felt. It also offers a rationale for the use of distraction and counter-stimulation, by cognitive therapies, which seize the opportunity to direct attention to some event other than pain. This advance shatters the old dualism in favour of an integrated whole, where mind and body or sensation and perception cannot be divided. This change had tremendous implication for occupational therapy in the area of pain: it provided a conceptual rationale for understanding how participating in activities that are meaningful to the patient might influence perception of pain and in turn decrease disability and improve function in daily life. For perhaps the first time, occupational therapy had a respected role in the management of pain particularly for the patient with chronic pain.

The last change comes from the new techniques of brain imaging, where we must now question the traditional separation of sensory and motor mechanisms. It becomes reasonable to propose that sensory events be analysed in terms of what might be the appropriate action. If this turns out to be reasonable, then therapies directed at active movement planning, posture and active participation in daily life may well influence perceived sensation. The chapter headings of this book show how the thinking of the editors and authors has expanded to incorporate this fundamentally new thinking about the origins of pain and the direction of new therapies.»

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