What is Shockwave Therapy?

How does Shockwave Therapy work?

How can Shockwave Therapy help with my tendon problems?

SWT works via a physiological process called mechanotransduction by which our cells respond to the forceful waves delivered by the shockwave machine by converting those mechanical stimuli to biochemical signals. This is very effective in reducing some irritable chronic painful musculoskeletal conditions, of which tendinopathy or tendonitis is usually at the top of the list. While our knowledge of where tendon pain comes from is still developing, we do know that extra blood vessel growth around tendons brings new nerves and subsequent pain receptors. Pain receptors come in two varieties:

• A-delta fibres, which transmit information related to acute pain to the brain (e.g. stubbing your toe or closing your finger in a door)
• C-fibres, which transmit information related to chronic pain to the brain (this is the type of pain that typically relates to tendinopathies as they are conditions that often develop through gradual stress and wear and tear over time rather than a sudden trauma)

Mechanotransduction from SWT has the capacity to inhibit these C-fibres in tendinopathy, ultimately creating pain modulation. One study of over 300 patients with a variety of tendinopathies had a reduced average pain rating from 6.25 to just 0.2. This was a year after the therapy, too. Further studies have corroborated these findings and there has not been any evidence of negative side effects yet. Rehabilitating tendinopathies usually involves fighting fires on two fronts: managing the pain and addressing the cause through physical therapy. By eliminating the pain, we can progress through the physical therapy much more rapidly, significantly reducing recovery times and costs of treatment.

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Does Shockwave Therapy hurt?

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Do Physiotherapy and Shockwave Therapy go hand in hand?

How much does Shockwave Therapy cost?

What is PFPS?

Patellofemoral pain syndrome (PFPS) is described as pain arising from the anterior or retropatellar knee region that increases with activities such as running, squatting, stair ambulation, hopping and jumping.
PFPS is a frequent complaint for individuals presenting to physiotherapy or sport medicine clinics. Studies report a high incidence in active populations, with females, particularly young females, affected more often than males. Pain influences short- and long-term prognosis requiring clinicians to deliver early interventions, especially because there is an increasing body of evidence suggesting that PFPS can last from 5-8 years to 20 years in the worst cases.

What causes PFPS?

It is generally accepted that PFPS arises from a multifactorial aetiology and that the exact source of symptoms is unclear. Suspected areas that could trigger PFPS are proposed to be all structures of the knee that are innervated, such as:

• Articular cartilage
• Subchondral bone and periosteum
• Vascular tissue
• Synovium and capsule
• Lateral retinaculum
• Fat pad

There are three main theories on the origin of the pain:

• Patellar malalignment or maltracking
• Overuse
• Trauma

The most accepted theory is the first but, in order to understand it correctly, it is important to introduce the concepts of biomechanics and kinematics. Biomechanics is the application of mechanical laws to the locomotor system of the human body, whereas Kinematics is a sub-area of biomechanics that studies the relative motion between two consecutive segments of the human body. In our case, we shall discuss patellofemoral kinematics as the motions between the two articular surfaces forming this joint, the patella and the femur. It is believed that small changes in the patellofemoral kinematics (in concrete a malalignment or maltracking) create increased shear stress inside the joint thus leading to PFPS development. Patellofemoral kinematics are influenced by how our lower limb moves in the space. Some individuals express abnormal lower limb kinematics altering the dynamic quadriceps angle (Q-angle), which is the angle formed between the quadriceps muscles and the patella tendon.​

Excessive dynamic Q-angle has been reported in females with PFPS and it is believed to create a lateral patellar displacement, increasing lateral pressures within the patellofemoral joint during anomalous motions of the lower extremity. There are also scientific reviews concluding that certain radiological measures of patella displacement are associated with PFPS. Lower limb kinematic abnormalities that increase the Q-angle are often neglected or missed in individuals playing sports. Some of them include:

• Abnormal foot pronation
• Tibial and femur internal rotations
• Knee abduction/valgus
• Hip adduction and internal rotation
• Contralateral pelvic drop

Physiotherapists have the skills to recognise lower limb kinematic alterations underpinning the problem and, with the right intervention, help restoring normal movements to treat PFPS.

However, it is important to remember that not all individuals suffering from PFPS display abnormal kinematics. This is because PFPS could also be related to overuse or trauma. Overuse refers to the performance of prolonged activities/movements that exceed the physiological capabilities of the patellofemoral joint and associated tissues. For example, in some people excessive amount of running or jumping could irritate the joint thus triggering patellofemoral joint stress and the onset of pain. This could also occur because of direct trauma, like when falling from a bicycle and lending directly to the patella.

What are the main symptoms of PFPS?

Symptoms of PFPS vary greatly among individuals, but the most common are the following:

• Peripatellar pain (diffuse, anterior, retropatellar, anteriomedial or anterolateral)
• Pain during prolonged sitting, running, stair climbing, kneeling, jumping or squatting
• Tenderness on palpation in peripatellar region, compression
• Pseudo-locking (not true locking, meaning that the knee can be manually un-locked)
• Giving way (often occurs on stairs)
• Swelling can be present
• Stiffness (especially after prolonged sitting)
• Crepitus (can also be painful)
• Decreased flexibility of quadriceps, hamstring, gastrocnemius and soleus
• Weakness of quadriceps and gluteal muscles
• Abnormal foot position can be present

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Physiotherapy Management

Multimodal physiotherapy can significantly reduce PFPS symptoms. The best multimodal approach incorporates:

• Manual therapy
• Acupuncture
• Strength exercises for quadriceps and gluteal muscles
• Patellar taping

There is strong evidence that this approach is effective at 6 weeks in reducing pain and improving functionality. It will also be important to consider other variables, if present, such as foot posture assessment, stretching and account for psychological barriers that can be present in individuals with fear of pain.

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Osteoarthritis (OA) is defined as joint pain accompanied by functional limitation and reduced quality of life and its clinical features are loss of cartilage, bone remodelling and associated inflammation. The three most common large joint to be affected in the body are, in order, knee, hip and shoulder. OA is more common in women and the aging population. Although the gold standard diagnostic test is radiographs, the National Institute for Health Care Excellence (NICE) in the UK suggests that diagnoses can be made if the person is 45 or over, they have activity-related joint pain and either no morning joint-related stiffness or morning stiffness lasting less than 30 minutes. However, in clinical practise it is also important to exclude other sources of joint pain:

• Knee: it is important to exclude patellofemoral pain, meniscal and ligamentous injuries.
• Hip: differential diagnosis must consider hip impingement and labral tear.
• Shoulder: rotator cuff tendinopathy and referred pain from the cervical spine must be ruled out.
• Important differential diagnosis also includes crystalline arthropathies (e.g. gout), inflammatory arthropathies (e.g. rheumatoid arthritis), septic arthritis and malignancy.

Early management of OA is nonoperative consisting of a holistic approach incorporating education and self-management strategies, weight loss, physiotherapy and exercise. Conservative management can help reducing pain and improving joint mobility. However, intra-articular injections can be considered for cases of moderate to severe pain as they are a cost-effective treatment.

This blog is intended to educate patients to what OA is and what its clinical signs are in the three most affected large joints of the body. For further information, please visit the NICE website at https://www.nice.org.uk/guidance/cg177.

Knee OA

CHARACTERISTICS

Knee OA presents with joint pain and stiffness. It can affect either the tibiofemoral joint (in both medial and lateral compartments) or the patellofemoral joint, or both. As stated above, people are normally above 45 years of age, women are more affected than men and they suffer from either no morning joint-related stiffness or morning stiffness lasting less than 30 minutes. People describe the problem as ‘activity related joint pain’, with the most common aggravating activities being any weight-bearing task (e.g. walking, stair climbing, kneeling, squatting) and with prolonged sitting and resting creating increased joint stiffness. The knee could also experience giving way (a sensation of instability) due to pain or muscle weakness. Knee swelling is common but often joint enlargement can also be observed. Reduced knee range of motion (ROM) is likely.

MANAGEMENT

• NICE guidelines: early management is nonoperative and it consists of a holistic approach incorporating education and self-management strategies, weight loss, physiotherapy, and exercise. Physiotherapy consists of manual techniques, including soft tissue massage, trigger point therapy, passive mobilization, and joint manipulation. The best forms of exercise for knee OA are light aerobic training and local muscle strength work, combined with active mobility exercises and proprioception/balance training. Static cycling is also effective in reducing pain and improving function (pedal exercises can be considered for those unable to get on/off a bike). Aquatic therapy can be performed as inside the water the joint is out of gravity force and the resistance offered by the water can facilitate muscle activity and joint motion. Footwear and orthotics can be considered if appropriate to correct gait abnormalities and improve walking function. However, in cases of severe pain it is also important to consider walking aids.
• Referral to orthopaedics: the physiotherapist should consider referring the patient when there is poor response to the therapy and pain management strategies and/or in cases of severe functional limitations.
• X-ray: only to be used to rule out other pathologies or a sudden deterioration, not just to confirm OA diagnosis. X-ray in weightbearing will show the amount of degeneration, location of OA, stage of OA and loose bodies within the articular surfaces. However, it is important to remember that there is a poor link between visible changes on X-ray and OA symptoms (patients can have little degenerative changes but a lot of pain or vice versa severe changes on X-ray may not result in severe pain).
• Corticosteroid injections: injections are beneficial to reduce pain in moderate OA changes. However, the pain relief effect produced by the injection will only last for up to three months, thus continuing physiotherapy and exercise following injection is critical. Usually, patients should not have more than two injections per year, and they must know that injections tend to become less effective the more you have them. Additionally, people should be informed of the concerning degenerative effect that repeated injections could have on knee cartilage over the years.
• Knee Replacement: it should only be considered when the pain is severe, it is present at night with disturbed sleep pattern, it is not controlled with analgesics, it is not responding to conservative measures and there are severe functional limitations.
• Arthroscopy: it is not recommended unless there is true knee locking with loose body within the articular surface.

Hip OA

CHARACTERISTICS

Hip OA patients are usually above 45 years of age with 10% them being over 65. Pain is located either in the groin area, anterior and lateral to the hip or posterior to the hip. Hip OA may have pre-disposing factors leading to its development (e.g. job, sport, joint anatomical defects). As stated above, pain can present with either no morning joint-related stiffness or morning stiffness lasting less than 30 minutes. Aggravating activities include weight-bearing tasks and activities involving deep hip flexion, such as putting shoes on, cutting toenails etc. It is common to also have limited hip mobility, not just pain.

MANAGEMENT

• NICE guidelines: early management is nonoperative and it consists of a holistic approach incorporating education and self-management strategies, weight loss, physiotherapy, and exercise. Physiotherapy will use manual therapy and mobilization techniques. Exercise is based on gluteal muscle strength to address poor lateral stability of the hip. During exercise, emphasis should be placed on control rather than strength only. Light aerobic training, static cycling and aquatic therapy can be used exactly like for knee OA (see above). Footwear and orthotics can be considered if appropriate to correct gait abnormalities and improve walking function. However, in cases of severe pain it is also important to consider walking aids.
• Referral to orthopaedics: the physiotherapist should consider referring the patient when there is poor response to the pain management strategies and/or in cases of severe functional limitations.
• X-ray: it is usually the first investigation to consider for diagnosing OA.
• MRI: it is normally more effective in detecting early OA changes.
• Corticosteroid injections: there is limited evidence for OA hip. Intra-articular injections should only be considered as an adjunct to core treatments for the relief of moderate to severe pain in people with OA.
• Hip Replacement: it can be considered in cases of advanced degenerative changes, when daily activities are severely affected, when there is pain at rest and/or at night with sleep disturbance, when pain medications are no longer effective and when there is a considerable reduction of walking distances. Patients must have tried conservative strategies prior to surgical intervention.
• Resurfacing: it is normally considered for younger population with dysplasia or deformities.

Shoulder OA

CHARACTERISTICS

Shoulder OA can present as pain that feels deep, inside the joint. It most commonly affects patients above 60 years of age, although anyone above 45 can have it. Patients do suffer from activity-related joint pain with either no morning joint-related stiffness or morning stiffness lasting less than 30 minutes. The pain can ease with heat and analgesia. Joint movement would usually create crepitus (described as grinding, creaking, cracking, grating, crunching, or popping that occurs when moving a joint). The onset is normally long and gradual where the shoulder progressively gets stiffer. There may be night pain and disturbed sleep pattern.

MANAGEMENT

• NICE guidelines: early management is nonoperative and it consists of a holistic approach incorporating education and self-management strategies, physiotherapy, and exercise. Physiotherapy will include passive and active mobility techniques, soft tissue massage, trigger point therapy and joint manipulation. Exercise aims to strengthen the shoulder muscles.
• Referral to orthopaedics: the physiotherapist should consider referring the patient when there is poor response to the therapy and pain management strategies and/or in cases of severe functional limitations.
• X-ray: (anteroposterior and axillary view) is the best test for investigation and it can be used to confirm or ascertain the severity or OA.
• Corticosteroid injections: injections can be considered for moderate to severe pain.
• Nerve blocks: this medical procedure can be considered for temporary pain relief if patients are not suitable for surgery.
• Surgery: Total Shoulder Replacement (or Reverse Shoulder Replacement when there is a non-functioning rotator cuff) are to be considered as last resource for pain management and improvement of mobility and functionality.

Meniscal Injuries

The medial and lateral menisci are two important shock-absorbing structures preserving the health, integrity, and functionality of the knee. Their role is to serve as a cushion between femur and tibia and protect the underlying articular cartilage from being damaged by high-intensity vertical forces. Additionally, menisci increase the contact surface between femur and tibia, distribute stress across the knee during weight bearing tasks, stabilize and facilitate joint movement.

Menisci can be torn or completely ruptured, and the severity of the injury will impact on recovery and outcome. Below there are some examples of the most common meniscal tears:

Meniscal injuries can be classified in two main categories: TRAUMATIC and DEGENERATIVE.

Traumatic Meniscal Injury

What is it?

Traumatic meniscal injury often occurs in younger age groups. Most of these individuals are sport athletes below 40 years of age who have sustained a specific trauma in their knee, especially if they play contact sports. The most common traumatic event resulting in meniscal tear is a twisting movement on a semi-flexed, weight bearing knee. Injured people are usually unable to continue to play on after the trauma. Physiotherapists must always screen for the ligaments and, in particular, the anterior cruciate ligament as this can often get damaged by the same trauma. Traumatic meniscal injury is 5 times more common in males than females, because males are more involved in aggressive sporting. Depending on what meniscus is injured, the pain can be located either on the medial or lateral aspect of the knee. Posterior knee pain can often be present, and it is common when the tear is localised on the posterior horn of the meniscus. Common symptoms associated with a traumatic meniscal injury are locking, swelling and giving way of the knee.

What is the management?

Physiotherapy is always recommended as first line of treatment as research comparing 8-week physio programme made of strength, flexibility and proprioception work versus surgery demonstrated that surgery is no superior to physiotherapy. Pain management strategies will consist of rest, ice, compression and elevation in the short term. An exercise-based approach will consist of exercises to strengthen specific knee muscles. Physiotherapy should also address any impairment in mobility and stability if present.

When to request additional investigations or consider alternative solutions?

Once the diagnosis has been made by the physiotherapist, additional investigations are not required because in most cases they will not inform or change the management program. However, a physiotherapist can recommend an MRI scan for those patients experiencing true knee locking or for those who fail conservative management. Generally, if patients fail to respond to physiotherapy, surgical arthroscopy can be considered.

Degenerative Meniscal Injury

What is it?

Degenerative meniscal injury is a non-traumatic injury of the meniscus, and the onset of pain is gradual and insidious. Pain can occur after a minimal trauma (e.g. kneeling while gardening) or increased loading activity (e.g. a walk significantly longer than usual). Degenerative meniscal injury affects older age groups, and it is often associated with osteoarthritis in the knee. Squatting, kneeling and prolonged walking will often aggravate the knee pain. Pain can be localized on the medial, lateral or posterior aspect of knee. There is often knee swelling and giving way. However, differently than for a traumatic injury, the knee will rarely lock.

What is the management?

Physiotherapy management follows the knee osteoarthritis approach, incorporating education and advice, lifestyle modifications, analgesia and self-management strategies, weight loss, manual therapy techniques and exercise. The best exercise regime will include light aerobic training, local knee muscle strength work, active knee mobility and proprioception exercises. Static, low resistance cycling and aquatic therapy are also effective in reducing pain and improving function. Manual therapy techniques are supported by research if combined with exercise. Footwear and orthotic advice can be suggested by the physiotherapist if appropriate for the patient. Walking aids will be recommended for those individuals with significant pain.

When to request additional investigations or consider alternative solutions?

An MRI scan is indicated to assess the severity of the meniscal damage once physiotherapy has been unsuccessful. However, degenerative meniscal tears should always be considered on the background of osteoarthritis, hence a X-Ray can be suggested to confirm the diagnosis. It is important to remember that there is a poor link between visible changes on X-Ray and osteoarthritis symptoms. Corticosteroid injections are beneficial to reduce pain in case of early-moderate osteoarthritis but not effective for meniscal injuries. Injections will promote pain relief only for few months, their effect tends to reduce the more you use them, and you cannot abuse of injections because, over time, they are shown to increase the amount of joint cartilage degeneration. Therefore, it is always important to use injection as a complementary strategy to manage your pain and always continue with physiotherapy and exercises after you have had the injection. Degenerative meniscal tears can be treated with surgical arthroscopy but, especially for elderly patients with significant degeneration of the knee, there is the concern that more damage can be caused to the joint cartilage during the process. Therefore, often the surgeon will have to evaluate whether knee replacement is better. Knee replacement is generally appropriate for cases of severe pain with functional limitations, when the pain is not controlled with analgesics and the patient has failed physiotherapy.

Understanding low back pain

What is low back pain?

Among MSK injuries, low back pain (LBP) causes the highest burden with a prevalence of 568 million people in the world suffering from it. LBP is also the main reason for a premature exit out of the workforce. According to The British Pain Society, it costs an astonishing £10 billion on the UK economy. LBP is defined as pain arising from the lumbar spine, which can be divided into two big categories: “specific” and “non-specific”.

• Specific LBP accounts for 5% of the total cases.

Of this percentage, 4% is due to RADICULOPATHY (see the next section below for more information) and 1% is due to RED FLAGS, serious conditions that can present as musculoskeletal pain but require urgent medical attention. These Red Flags are: Tumor/Cancer, Infection, Fracture, Compression Pathology (e.g. Causa Equina Syndrome or Myelopathy), Inflammation (e.g. Spondyloarthropathy) and Metabolic disease (e.g. Osteoporosis). Physiotherapists must always screen for serious pathology at the beginning of the consultation and, if there is suspicion, onward referral to doctors and/or Accident and Emergency will be made.

• Non-Specific LBP accounts for the remaining 95% of the total cases.

The term “non-specific” means that it not possible to identify the exact cause of the pain. Surprisingly for many patients, a definite diagnosis cannot be achieved even with radiological investigations (such as X-Rays or MRI scans). Having said that, transitory changes in specific structures of the spine (discs and joints) can underpin the onset of pain in most individuals (see below).

LBP is usually categorized in 3 subtypes based on the duration of the pain: ACUTE (less than 6 weeks), SUB-ACUTE (between 6 and 12 weeks) and CHRONIC (longer than 12 weeks).

What can cause acute low back pain?

In most cases, people suffering from LBP who attend physiotherapy clinics will have a pain either discogenic or arthrogenic in nature.

Discogenic LBP originates from the discs of the spine when they have sustained specific changes overtime, such as dehydration or degeneration. These changes will initiate a cascade of peripheral and central events ultimately resulting in the perception of pain. However, you must not be fooled: disc dehydration/degeneration occur in every individual in response to aging and load exposure overtime and having some minor alterations in your spine does not mean that you will feel pain. In fact, discs are designed to modify their shape in response to sudden or repetitive load, acting as “shock-absorbing elements” of the spine. Minor protrusions or herniations are present in most individuals, and they will neither create pain nor impact on people’s ability to function. However, even if disc changes do not compromise spinal health in most cases, specific types of alterations can underpin the onset of LBP. For instance, when the disc bulges significantly out, it can sometimes result in one of the following:

• a narrowing of the spinal canal with potential compression of the spinal cord (SPINAL STENOSIS);
• an inflammation that irritates the exiting nerve root (RADICULAR PAIN);
• a compression of the exiting nerve root leading to alterations of the neural function, such as pins and needles, tingling, numbness, loss of power and reduced sensitivity (RADICULOPATHY).

Arthrogenic LBP originates from the joints in the spine called facet joints. This is more common in the aging population as joint pain is often the result of age-related arthritis, which can affect not only the joint itself but also its innervation, producing both local and radiating pain.

What can cause chronic low back pain?

In general, 90% of LBP cases resolve within 6 to 8 weeks with appropriate physiotherapy. However, in some cases symptoms can continue for longer and, sadly, some individuals will have long-standing pain. Chronic LBP occurs when the impairment is more localized in the central nervous system than in the musculoskeletal system. This happens because our nervous system is “plastic”, where neural plasticity refers to the ability of the nervous system to change its activity in response to internal or external stimuli by reorganizing its structure, functions, or connections. Stimuli that can trigger this include bad prolonged postures, wrong repetitive movements, traumas, strains and surgery. In chronic pain states, these stimuli will produce a cascade of events in the body that will ultimately affect the nervous system. Examples of these events are:

• Tonic and persistent stimulation of nociceptors (nociceptors are sensory receptors that detect signals from damaged tissue);
• Altered excitability of nerve fibers (nerves start firing electric impulses randomly and spontaneously rather than in responds to a specific stimulus);
• Modifications of ion channels with consequent altered signal transmission (transmission of a signal within a neuron is carried out by the opening and closing of ion channels; alterations of these channels will cause abnormal transmission of signals from the periphery to the central nervous system and vice versa);
• Up-regulation of specific genes (neurons will increase the expression of specific genes which in turn will amplify the number of receptors in their surfaces: with more receptors, neurons will become more sensitive to specific signals, thus responding more frequently than what they should to peripheral stimuli).

The result of the cascade of events will be the perception of pain despite the absence of an ongoing injury.

Can physiotherapy help with acute and chronic low back pain?

Yes, it can. Physiotherapy uses a series of interventions to help people reducing or eliminating pain from their back. For chronic pain conditions, it cannot always be possible to get rid of the pain completely, but improvements in functionality, mobility and quality of life will be achieved with the right therapeutic approach. Management strategies used in physiotherapy include:

• Provide people with education, advice and information about their problem, tailored to their needs and capabilities to help with self-management strategies
• Prescribe bespoke exercises
• Use manual therapy techniques (spinal manipulation, mobilization, soft tissue techniques and massage)

What are musculoskeletal injuries and why is physiotherapy important?

What are musculoskeletal injuries?

The WHO estimates that approximately 1.71 billion people suffer from musculoskeletal (MSK) injuries worldwide. These injuries range from those that arise suddenly and are short-lived to lifelong conditions associated with ongoing functioning limitations and disability. MSK conditions comprise more than 150 injuries affecting the bodies of young, adults and elderly people. These injuries are typically characterized by pain, limitations in mobility, dexterity and overall level of functioning, reducing people’s ability to socialise, work and enjoy life. MSK injuries include problems affecting:

• Joints (e.g. osteoarthritis, dislocation, instability, hypermobility and stiffness)
• Bones (e.g. osteoporosis, osteopenia, fracture and bone stress response)
• Muscles and Tendons (e.g. contracture, spasm, tear, rupture, inflammation and tendinopathy)
• Ligaments (e.g. laxity, sprain, tear and rupture)
• Spine (e.g. acute and chronic neck, upper back and lower back pain)
• Peripheral nerves (e.g. carpal tunnel syndrome, radiculopathy and radicular pain, sciatic nerve injury and entrapment neuropathy)
• Multiple body areas or systems (e.g. rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, ehlers-danlos syndrome, fibromyalgia and complex regional pain syndrome).

Why is physiotherapy important?

MSK injuries are the highest contributors to the global need for rehabilitation services. Physiotherapy is at the forefront of rehabilitation services as it is an evidence-based practise and takes a ‘whole person – holistic’ approach to injuries, aiming to promote health and wellbeing in every individual suffering from pain. Physiotherapists help people affected by MSK injury, illness or disability through a series of interventions, such as movement and exercise, manual therapy, acupuncture, education and advice. Physiotherapists maintain and optimize health and fitness for people of all ages, helping patients to manage pain, prevent disease and achieve the highest level of quality of life. Physiotherapists are degree-based health-care professionals who deliver much more than a simple massage. Some physiotherapists have gone through extensive post-graduate training and are able to, among other things, independently prescribe medications and perform soft tissue and joint injections. Many others are involved in education, research and service management.