Education and advice: the foundations of our profession

“A well designed Randomised Controlled Trial (RCT) regarding acute WAD, demonstrated recently that 6 sessions of multimodal physiotherapy (advice, exercise, manual therapy) were slightly more effective, but not on a significant level, than just one physiotherapy session that focused mainly on offering advice (Lamb et al., 2013).

In concordance with the previous findings, Michaleff et al., (2014) in a pragmatic RCT found that a 30-minute educational session containing a package of consultation, informational booklets and simple advice can be as efficient as a 12 week exercise program delivered by physiotherapists, including manual therapy, CBT, posture education and sensorimotor training. The authors emphasised the impact these findings can have on the current cost of WAD treatment as they could potentially decrease the number of unnecessary visits to healthcare practitioners”

Thanks to my friend Vasil for these papers


Bloody hell! It is the first thing I thought when I read it.  Basically it is saying that education & advice are as important as the treatment.

Unfortunately there are a lot of practicioners who spend thousand of pound in courses, medical instruments and electro-medicals and loose the contact with the most important part of our job, the foundation of our profession: EDUCATION AND ADVICE.

What do I mean?

I mean trying to understand patient’s beliefs (regarding the issue) and expectations (regarding the rehabilitation) and to use them in order to get a successfull outcome.

As Prof. Lorimer Moseley said: “Anything that changes your brain’s evaluation of danger will change the pain”. Most of the patients come to the initial assessment very scared and worried, especially after  road traffic accident. Few days ago a client of mine told me: “I cannot believe I can feel so much pain at this age: I damaged something”.

After a proper initial assessment, after you realise there is nothing major, the first thing you must do is to calm down the client, explain that pain is not synonym of damage, that is influenced by several factors that are not strictly body related (especially after a road traffic accident) etc…

Middle age people are very concerned about the MRI and XRAY findings. Expressions like “degenerated spine”, “degenerated discs”, “bulging”, “osteoarthritis” , “sprained ligaments” etc.. are all expressions that poison the mind of the client making him think that there is a certain connection between the physical damage and the pain he/she is experiencing.

“So if my spine is degenerated how can I get better? Am I doomed to pain for the rest of my life?” that is what lot of people ask me at the initial assessment.

Until you don’t change these beliefs there is no way to make him/her feeling better.

That is why, as my friend Giancarlo Russo says, if you approach the client in the right way and if you communicate properly 90% of the job is already done; what you do on the treatment couch is not so  important anymore.

However, there  cases in which it is impossible to change people’s belief. If you treat a 70 years old client with pain on the left sacro-iliac joint is very difficult for that person to accept the idea that the site of the pain is not where the problem is. It is difficult for that person to accept the idea that if you treat the thoracic spine and the diaphragm the pain will calm down.  In this case if you don’t manage to change his/her beliefs you have to be smart and to use them to fix the problem.

A 10 minutes massage on the painful area will be enough to make the client happy and to get “potential” on him/her (we will explain this topic in another post) and you will still have time enough to do all the techniques that you believe are necessary.

Treatment is very important but it becomes meaningless without the initial interview. On the other side a profitable interview could be not enough without a proper treatment.

I don’t really know what a “proper treatment” is, I can just tell you that, with the right advice and education even a normal massage could be enough to fix a non-specific-low-back pain or a non-specific-neck pain.

You can spend thousand of euro, quid or bucks in courses with pretentious and exotic names but, if you are not able to deal with people, to approach them properly and to give the right advice you will not go any further: you will always be a mediocre therapist.

Thanks to my colleague Adam Meakins to let me share his beautiful picture: the physio treatment pyramid

Thanks for reading


The reason why you SHOULDN’T take your responsibilities

One of the most precious things we have as human being, living in a “developed society” is freedom.

Our progenitors fought and died for it and we are one of the first generation of people living in a “free” world. We are free to go where we want, we are free to choose our job, we are free to choose our partner and to change our future.

We are ultimately free to change our life when we want and how we want.

But how can we be certain of this?

We don’t have a dictator issuing rules and regulations, we are in charge of ourselves.

Regrettably, we still share and experience miserable periods, the reality is we are not free at all – we are slaves to ourselves.

Our lives are only a miserable fiction and we are not free at all: we are slaves of ourselves.

Let me explain this further (my poor knowledge of English will not help me)

Our demise begins when we are born, we were instructed to take our responsibilities –

“You have to act in this way because that is how real men/women behave”

“We are advised to go to University – otherwise you will find no job”

“You have to be a loyal to your partner because you loose your morals if you do”

“Get married and have kids because you are already 30 years old!!”

You get the picture…


The reason why humans have been so successful and have conquered the world is because we are the only animal in the Earth able to reason.

“Logos” (the rational principle that governs and develops the universe) is what characterize us mainly.

Since the COGNITIVE REVOLUTION around 70 000 years ago, we have been able to go beyond the reality, to go beyond the simple things we could touch, smell or see.

We started creating common beliefs (the belief of a God taking care of us, the belief of a nation that has to be defense from someone else etc..) and we managed to cooperate together, building villages, cities, empires, republics and…Gods.

There is no way to make thousands of people working together unless they work together  for a common illusion.

If you ask to a monkey to give you the only banana it has promising it limitless bananas in the monkey’s paradise it will deny it. It will never accept  (Harari dixit).

With a human you can do it because we have the possibility to go beyond the reality of facts in name of something bigger.

That is our biggest strength and our biggest ruin because we build thousands of golden jails inside ourselves.

Day after day we accumulate tensions after tensions because we are force to do things we don’t like and we don’t want.

Forced by ourselves….

Victims of our own mind we kept living a miserable life scared and worried for things that don’t exist.

Our problems come basically from the fact that there is a fight inside us between the ethical and moral code imposed by our parents, by societies and by religion and OUR OWN CODE composed by  things we want to do in our own way.

In 99,9% of the cases the code we received from the society is much stronger than ours and we end up following it. So today we decide to go to University because our parents told us or put pressure on us. Then we choose that career because that is the natural consequence after studying so hard. Tomorrow we will get married and we will have kids because THAT IS HOW SOCIETY WORKS! Because that is why we are on this planet: keep reproducing and so on.

We study medicine for 6 years and then we will end up doing the doctors just because we have studied for it. Where is written that I cannot do the post man even if I got a degree in another field??

Again: because we are slaves of ourselves and of the preconceptions of the society.

We choose a partner and we are loyal because that is how a real man or a real woman behave.

Regrettably, there is written nowhere how a “real” person should be. All this rules and prejudices are sons of the decisions that someone else, hundreds of years ago, took for ourselves.

Imposing our code on the society’s one is the real key to be happy, according to me.

But it is fucking hard!!!!!

Responsibilities are defined by our society and beliefs; they change according to the latitude, to the hystorical period we are living and according to other variables. Ephemeral rules that we inherit and that ruin our life.

Yes ,basically I am saying all the opposite of what you have been told!


Day after day we accumulate tensions because we don’t really do what we want and, after a while, we start having the symptoms. These symptoms could be menthal issues, chronic pain or skin diseases etc…; doesn’t matter. We will start paying back a life spent doing things we didn’t really want to do.

At the conclusion of this delirium I can say that replacing completely the ethical and moral code we received with our own one IS PRETTY IMPOSSIBLE,BUT, WE CAN FIND A COMPROMISE TO LIVE OUR LIFE BETTER. WE REALLY HAVE TO STOP TO DO THINGS WE DON’T WANT WHATEVER THEY ARE  AND TO START IMPOSING OUR RULES.

Little by little, in our daily routine



Thanks for reading and thanks to Stefano Benemeglio who inspired me.


Low back pain in London vs Low back pain in Nottingham

A few years ago a colleague of mine asked me to weigh up on a scenario – if a person living in a small city like Nottingham, experiencing low back pain could be treated and approached in the same way of a one living and working in a huge crazy city like London.

Generally talking of course!

I didn’t understand the question entirely; low back pain is low back pain and the spine remains same, it ultimately doesn’t change according to the latitude.

A spine doesn’t your lifestyle change.

After one year working in UK and after 3000 treatments provided to a variety of people with different cultures, backgrounds and beliefs, I can finally say – Giancarlo you were right.

The way I approach a client in London is very different apposed to when I was living in my little city in Italy.

To expand on this further

Working in places like Victoria and Canary Wharf means that you treat business types: accountants of large multinational companies, lawyers, engineers and traders.

I am talking about people who live in the office.

I am talking about people who works 14 hours a day

I am talking about people who start working at 7am and have to commute 1 and half hours to the office.

I am talking about people who are 35 years old or younger and their hair is grey and thin, in addition of this the bowel is fucked up and they live with IBS.

I am talking about people who ask me to finish 10 minutes earlier because their manager needs them in the office, in front of 3 screens.

I am talking about people who live with the sympathetic nervous system working their asses out like a motherfucker. People who sleep 5 hours a night and take drugs to keep going.

They come to the clinic sacrificing their lunch-time and well earned breaks yet complain about neck pain and headaches.

According to what I studied I should assess them and treat them following a specific protocol (if we can speak about protocols in rehab).

I should do my mobilisations, my PA (physiotherapeutic techniques) and I should correct the way they move, I should make them train the core (so you can stabilize the back, like someone says!) and I have to make sure that they do the exercises at home (maybe they live in Cambridge, arrive at home at 10pm, they  have to eat and to spend few mins with the kids.. I am sure they are looking forward to exercising)


Once I realise, after a deepened initial assessment, that there are no major issues, no neurological signs, nothing that requires a “proper” treatment or a specialist consultation, but there is just tension and stiffness in the soft tissues due to several hours spent in the chair what I do is to relax the patient.

The goal of the treatment is to switch off for 30 minutes the sympathetic nervous system.

What I generally do is to do a gentle and pleasant soft tissues treatment (myofascial release, positional release etc..) and I finish with a 15 minutes massage or a hypnotic induction (I don’t deny a manipulation to anyone btw).

The result is: everyone happy and better.

Doesn’t work? I change, no problems.


Thus spoke Zarathustra

Thank for reading


Pain is not in my mind!! It is real!!

As a physiotherapist I see up to 15 people a day struggling with pain. “Pain is not in my mind, it is real” is one of the most common expression my clients say when I ask them about “their” pain. Especially when one of my patient refers he is going through a period of high stress (basically 90% of the people living in London!) and I make him notice that could influence the pain experience the response is him repeating like a mantra: “my pain is real”!!!
He is concerned about the fact that I could underestimate the problem and he wants to make me focus on his genuine sufferance.
He is concerned about the fact he got a physical damage and that is the place from which the pain come from! When I try to move his focus from the site of the pain and from the equation pain = damage to his mind and to the deep processes which create pain the client thinks I am not taking his problem seriously.
Well, pain is only in our mind ………..Let me explain it better

The International Association for the Study of Pain’s describes pain in this way: “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”
Pain is an experience and it is due to several factors. Pain in an answer generated, largely, by the limbic system (which influences the endocrine system and the autonomic nervous system and that is involved in motivation, emotion, learning, and memory) and by the neuro cortex (especially the dorsal posterior insula) as a result of different input which arrives from the periphery (joints, muscles etc..) and from the centre (mood, beliefs, expectations etc..).
Pain is not only something generated by “the structure”, by “the body” but actually a complex experience elaborated by our mind as a result of different input, that we will examine in depth in another blog, and highly influenced by attention, beliefs, expectations, mood, personal issues ongoing etc..

Any kind of pain, for definition, is REAL! Even the phantom pain

So, in summary, we can conclude in this way: PAIN IS NOT SYNONIM OF DAMAGE

Thanks for reading


Are you able to take responsibilities??

One of the most annoying client any medical professional has is the one who wants the miracle.

Talking about my experience as a physio and hypnotherapist a good 20% of our daily patients is the one who come to the clinic moaning for a low back pain (for example) that, according to him and to the GP, is due to a damage between L5-S1.

The patient comes to the clinic very worried and concerned; the MRI had spoken and the verdict is ruthless: spine degeneration!!! (?)

The guy comes inside my room: he is 20kg overweight and he took the lift to join the clinic at the first floor.

The anamnesis starts and I try to get a good overview of the medical condition but the patient starts giving the first signs of impatience: I came for my bloody spine degeneration, treat it and make me feel better I bet he would rather to say.

Even if he is reluctant he answers to all my question and the summary is scaring: he doesn’t do any physical activity (he works 50 hours a week and after it he goes home or to the pub), he consumes a notable amount of alchol during the week, the diet is full of fat and sweets without any consideration of fruit and vegetable, he smokes 20 cigarettes a day, he spends the spare time and the week end on the sofa or in the pub and he takes the car even to go from the kitchen to the living room.

“How can I do now? The doctor said I have a degeneration that’s why I have pain in the back. Can you fix me?”

The second session, at the objective assessment, the range of motion of the spine is better, there is less tension on the soft tissues, and you can feel the client moving better but, BUT, he still refers a terrible pain: maybe even worse.

The client is desperate and he wants you to use the magic stick.

At this point  I tell him what I already told him at the initial assessment:


“But what If comes back again? Maybe is better if I speak with the surgeon and we can fix it” he replies scared

Again I tell him that he cannot get better if HE IS NOT READY TO RENOUNCE TO THE BAD HABITS THAT CAUSED THE PROBLEM.

You have to move, to walk more often, to reduce drastically the amount of alchol you drink, to smoke less,to spend the week end walking, going to the park etc.. you have to eat better ETC.. ETC…

The patient at that point says thanks, he pays and he doesn’t come back.

Lack of communication? Bad management of the problem? Or simply, no intentions of taking any responsibilities??

No shrortcuts to the success or to a better life. NO shortcuts for the resolution of a problem: only hard fuckin work.

The deep reason , in a lot of  cases, is that most of the people are not able to take responsibilities: they lay the blame on other people or on unchangeable situation (like the spine degeneration or whatever it is).

Remember that the responsibility for your health is yours and ONLY yours. The professional you pay can just show you the way you have to take  but most of the responsibilities are on you!

So, Do you really want to get better?

This case is a provocation and a little bit exaggerated but it helps to describe a category of people we meet very often in our life.

Thanks for reading