Monthly Archives: September 2014

Evidence-Based Physiotherapy: A Crisis in Movement

Being at the tail-end of a PhD in Evidence-Based Medicine, I recently re-read Trisha Greenhalgh et als’ BMJ Paper Evidence based medicine: a movement in crisis (see what I did there?) and now provide a plea for Physiotherapists / Physical Therapists the World over.

We are part of a wonderful profession, and also part of a fast changing world. It seems a good time now to reflect and act upon the past 20 years of growing evidence and information. These are some random reflections on Greenhalgh et als’ paper with Physiotherapy in mind.

Physiotherapists, please read and understand published data, but realise that this data is only meaningful when positioned within the narratives and socio-cultural contexts of our patients and our own experiences. Allow data – if sufficient – to free yourself from traditions and habits. Don’t be swayed by preposterous gadgetry and pretty colours but always look towards the data to drive positive ways of developing your practice. Stop handing out leaflets.

Human observations are prone to biases of perception and memory. Robust studies are designed to reduce such biases. Human observational biases can be easily controlled for by intellect. Most trials fail to control for biases sufficiently. Human observational biases are still evident though, for example the perception biases seen when interpreting the results of a trial. Treat real-life experience and outputs from studies as equally valid sources of evidence, which can both be highly fallible.

Stop inventing complex and unnecessary classification and diagnostic systems. They are not needed. Sub-classification is important, so pay attention to high quality studies which allow us to learn which interventions suit which patients. But the best systems are the simplest. Be aware though that the best sub-classification systems will also eventually sub-class down to N=1. At this point, population study derived data start to lose relevance. Evidence for patient management for the N=1 (i.e. your patient) needs to come from the source (i.e. your patient).

Touch people who need touching, this is therapy. Don’t touch people who don’t need touching, this is battery. Talk with people who need talking with, this is therapy. Judge when this becomes meaningless. Educate your patient by all means, but also let them educate you.

Pain science is undoubtedly important in evidence-based pain management. Pain scientists have reminded us that we have brains. That’s good. Heed pain science data, but stop fawning over pain scientists. They are not Gods. We no longer need ‘institutes’ and ‘organisations’ of pain science. If the data is good enough, it will speak for itself. Don’t fall into the trap of moving from ‘clinical guru worship’ to ‘research guru worship’. There are no gurus. Don’t be drawn-in by general theories of the world, e.g. pain, which are underpinned by fragile evidence, but do understand the potential ways forward such evidence might point. If you are a disciple of such trends, stop posting random quotes from random ‘pain’ therapists as if this were some sort of confirmatory proof of theory. It’s not. The easiest thing is to stop being a disciple, and start to think for yourself. A bit like a professional would. Ignoring biological aspects of our patients’ complaints is evidence-based silliness. Calls to abandon a biomedical model is evidence-based moronicy. And downright dangerous. Psycho-social dimensions are of critical importance to our reasoning and management. So is differentiating non-specific back pain from aortic aneurysm.

As a science, let us learn from other sciences. Experimental physics provide excellent data describing the Universe, but is reserved in making inferences to future events. Theoretical physics uses this data to better understand the world and consider ways to move forward. Where are our theorists?

As a human-centred profession, let us learn from the humanities. The idea of causation on which all physiotherapy research is based is 266 years old and philosophically and sociologically un-sound. Why don’t we look at developing research methodologies based on enriched notions of causation? Throwing data onto a stressed-out workforce won’t make that workforce do evidence-based practice. It will just stress it further. Let’s look at ways in which change can occur in complex social structures.

If you must adhere to clinical guidelines, then by all means do so but bear-in-mind that guidelines are more often than not administrative and political tools, with any clinical component aggregated out to a meaningless level.

Physical activity and exercises are, surprise surprise, looking like the things that really matter in our game. Movement is everything. Most of the time it doesn’t really matter too much how that occurs, as long as it does occur. It might involve touch, it might not. Movement helps people contribute to society and it keeps the world going. It also delays the onset of things like death. However, Government health and wellbeing agendas are weak and meaningless. Allow your patient to set their own health agenda. We all need exercise, but we don’t all need to do 50 one-arm pull-ups on barbed-wire with baying wolves at our feet. Nor do we need to run through man-made pools of mud pretending we’re in the army. Our job should be focussed on using the best of the data to work with our patients in a search of a way to restore and rehabilitate meaningful movement whether they have had knee pain, back pain, a stroke, respiratory disease, or cancer.

When talking with patients, don’t use relative risk and probability data in your conversations. Even really clever people don’t understanding what these mean. Incorporate absolute risk into your reasoning, but judge when and to what extent it is useful to share with your patient.

If you are organising a conference, try and engage delegates better by having fewer, shorter presentations (say, 10 minutes) and allow more time for questions (say, 40 minutes). If you are a conference delegate, ask questions. Conferences are still a valid way of sharing data and thought, but this only works if there is a two-way communication channel. Evidence can only be made meaningful via discourse.

If you are a research funder, PLEASE STOP FUNDING RIDICULOUS RCTs. Fund the good ones, of course. But you are the only people in the whole world who can facilitate a better understanding of how people manage multiple sources of information in complex social situations. Can you please fund work into this. This is evidence-based practice.

If you are a journal editor, please facilitate the dissemination of thought and knowledge towards understanding the integration of population data into individual decision-making, rather than worrying about your impact factor.

If you are a student, listen, engage, challenge. However, do not start your first day at clinical work by saying to your senior “where’s your evidence?” This is an utterly negative, unconstructive and unintellectual strategy. Rather, search for the areas of practice which could be better developed, work with others to develop ways to address these limitations. In the meantime, learn the craft of listening and communicating with your patients. You are the profession’s most precious resource. You are our future. Please be careful with the information you receive.

Greenhalgh et als’ paper marks a pivotal landmark in the course of evidence-based medicine. As they highlight, there is a lot of groundwork still to do, but the emphasis should firmly be on collaboration between all stakeholders. One dimension of Sackett’s original idea of EBM seems to have got lost over the last 20 years – the patient. Let Physiotherapy support the call for a campaign for real evidence.

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