Physiotherapy has long been moving towards higher standards in research and better quality of data. Many physiotherapists and sports therapists will only follow what has been proven in randomised controlled trials (RCTs). On the face of it this makes a lot of scientific sense. But have we stepped back and asked does this give a better outcome for those on the receiving end?
What Is Evidence Based Physiotherapy?
“An evidence-based practice is considered any practice that has been established as effective through scientific research according to a set of explicit criteria” (Drake, et al, 2001).
Which on the face of it seems reasonable. You wouldn’t want us to be carrying out any old rubbish on your as paying customer. But we are organic beings. We do not deal in ones and zeros alone. There are many shades of grey… from which one author has recently made a large amount of cash! Randomised controlled trials are not always possible for all aspects of physiotherapy research. Does that mean we shouldn’t use them?
“We should not start using interventions until there is sufficient evidence for them” (M Van Tulder WCLBP Nov 2010)
Which on first reading seems a little draconian and restrictive. It would certainly make for a boring day for therapists and clients alike at Swindon Sports Therapy! But what is “sufficient evidence”? Is seeing something consistently work not sufficient evidence?
What Is Evidence?
Let us take one of our day to day whizzy techniques as an example. Many people come in to see us with hip flexor problem or equally we suspect their hip flexors (psoas) are affecting their bio-mechanics. We do a strength test before and a strength test after our treatment to assess the affect of our intervention. In approximately 90% of cases strength is immediately dramatically improved. Has this been proven in a randomised controlled trial. No. How many times have I seen is work… thousands.
Nay sayers will immediately site placebo affect. Doctors I meet at dinner parties consistently do, usually within 5 minutes of hearing what I do! There then ensues a lively debate and I like to accuse doctors for trying to explain anything away that they don’t understand as placebo. That really gets them going! But if you’re going to dish it out you have to be able to take it back!
Happily a lot of said doctors are now our regular clients, placebo or otherwise. For me whilst I’m interested in how things work, so long as it does I don’t really care. I could go on much more about placebo but I’ve made a note to save that for another Blog.
Going back to evidence. Our good friend and renowned Physiotherapist LJ Lee strives for one day that:
“Anecdotal evidence is as valued as randomised controlled trials.”
Sure experienced therapists passing on their “evidence” of things they have seen to other therapists is valid. Those therapists can then take on those ideas. See them work, or not, for themselves and continue understanding new and better ways to help people.
Why Look Beyond Physiotherapy Research?
Firstly things can always be better. Secondly not all things work for all people. Thirdly the research itself would never move on if we didn’t! Let’s take the second point here. If I have a technique that I’ve seen work every now and then with clients with a certain condition. Lets say one in ten for argument sake. Am I going to use it? By strict research methods we probably shouldn’t. But if we fix 1 on 10 people with this condition am I going to use it; of course I am!
This more balanced approach we employ at Swindon Sports Therapy is beautifully summed up by Stackett, Straus, Richardson, Rosenberg & Haynes (2000) – “External Evidence can inform but can never replace individual clinical expertise”
Put in a considerably more amusing way:
“Evidence without clinical expertise is as useful as a supercomputer in a rainforest: the sight might be impressive, but it isn’t useful” Jules Rothstein 1999
Frequently what we see at the clinic conflicts with the research. One lady in particular springs to mind. By the time the results of her MRI scan had come back to confirm that she had acute nerve root compression we had her pain free and climbing mountains in Wales! Thankfully research in nerve root compression is moving on and this is actually quite a normal response. But it hugely conflicts with a large body of research.
My last and possible favourite quote which eloquently describes what it is to be a therapist: “The ability to exercise good judgement in face of imperfect knowledge” by Stephen Hall from his book Wisdom. No test we use is 100% accurate. No technique is 100% guaranteed to improve someone’s symptoms. We simply look to do the right thing ethically, socially and personally for each client.
As David Butler sums up: “The advantages of clinical reasoning approach is that it is responsive to new knowledge and evidence, is flexible and allows for change and growth.”
Conclusion – Evidence Based Physiotherapy
Hopefully you can see that evidence based physiotherapy practice is not the only way. It is absolutely an invaluable part of any Physio’s or Sports Therapists armoury in the battle against pain. But it is not the only way. If we only work with what has been categorically proven how do we evolve onto our next paradigm?
Surely science is about evolving theories. Coming up with ways to verify how accurate those theories are. Modifying the original theories for the betterment of the subject and the planet! My plea here to any therapist or prospective client is look beyond the accepted norm. How can we make this better? Always look for the latest innovations. Apply or use them yourselves and start your own body of research – your own experience and expertise. If that doesn’t work, try something else!
At Swindon Sports Therapy we pride ourselves on bringing together all aspects of the latest physiotherapy research and adding in a mix of clinical expertise. If one of the leading physio’s in the world is telling us something will work, we test it ourselves and see that it works, our clients tell us that it works, is this not evidence?
If you enjoyed this Blog you may also want to read our previous Blog: Is Traditional Physiotherapy Fundamentally Flawed?
This Blog first appeared on our Brighton Sports Therapy site.