40 percent of us hold a very strong belief that medical technology can save our lives and x any problem – that “more is better”. However many conditions in health are better off with a self-managed, active, low cost, educational programme such as is offered by physiotherapy. While I am prepared to offer a general opinion on this subject, the research is based on two common conditions, which reflect other less researched muscular skeletal problems. In high quality studies, both back pain and chronic knee pain demonstrate that the rate of surgery and associated disability fall when physiotherapy is the first level intervention. When a back pain patient receives an MRI before physiotherapy they are six times more likely to have surgery. Similar outcomes are found with chronic knee pain.

The key presenting problem with persistent knee and back problems is pain. And pain is a worldwide problem. Pain is “an unpleasant sensory or emotional experience, associated with actual or perceived tissue damage”. Pain is manufactured in the brain and is therefore heavily influenced by beliefs, stress, emotional factors, sleep, previous experience as well as mechanical factors.

Challenging the “more is better” belief is the fact that we must not overlook the overwhelming evidence that in many cases with invasive, expensive interventions the patient’s condition worsens. This is an inherent risk associated with all invasive interventions. Patient selection is critical.

With PhysioFirst there is a process of early triage in which early referrals can be made. Managing the neural signature of each person and condition early on is imperative.

There is a reasonable level of evidence that early intervention physiotherapy decreases over utilization of risky procedures and lowers overall health costs. As mentioned previously:

• MRI first and you are six times more likely to have surgery.

• You are five times more likely to have injection therapy.

• And far more likely to have an ER visit within six months due to recurrence.

• There is very limited/no evidence for surgery for low back pain, how- ever for leg pain (sciatica), surgery can work very well.

• Physiotherapy programs reduce pain and increase function with chronic knee pain.

• Practicing relaxation exercises improves wound healing by reducing the “stress response” and have been shown to help post-operative recovery.

Patients that respond to early physiotherapy do not go on to being high-cost users of the health system or suffer the consequences of long term pain. If early intervention physiotherapy does not work, then referral to a specialist or surgeon
is appropriate. The patient who has failed conservative physiotherapy programmes, however, is still better off; for some of these key reasons:


1). They have a good understanding of their problem/condition (i.e. well educated).

2). They will be given advice about managing persistent pain.

3). Able to keep active without fear of increasing pain by selecting exercises which are not harmful (e.g. cycling for the knee).

4). The injured area has been strengthened prior to surgery, which generally helps recovery post operation.

5). Other barriers to recovery such as stress, lack of understanding and lack of sleep can be addressed, again facilitating a better outcome post operation.

6). Overall, physical condition is better.

7). Is well prepped for surgery.


In my opinion, these patients will do better with invasive procedures as a result of conservative management.

In summary: “Physiotherapy First” is a sensible and low-cost starting point for the management of most acute and chronic joint and muscle conditions, overall reducing the need for surgery and reducing healthcare costs. Patients who do not respond to early access physiotherapy can still be referred on and will indeed be better prepared for surgery or whatever intervention is recommended.

Conditions in which PhysioFirst makes sense:

• Low back pain
• Neck pain
• Whiplash
• Shoulder pain
• Chronic knee pain
• Chronic hip pain
• Tendonopathy – all sites
• The principle of PhysioFirst applies to many conditions

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