Where physiotherapy gets logical
Physical therapy is a profession that struggles with identity. Not only do patients have a limited understanding of what exactly a physical therapist does, but physical therapists themselves have difficulty defining what makes a physical therapist. This identity crisis is a multifaceted issue, but one of primary contributors is the idea of defining the physical therapy profession with particular interventions.
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One of the arguments I see used as a way of quickly disregarding published evidence, particularly those with negative results, is the idea of internal validity coming at the expense of external validity — essentially that the trial is “too controlled”, not representative of the patients actually seen in the clinic and does not account for certain variables. This is absolutely true, there are plenty of issues with generalizability from research into practice. However, I am not convinced that this general argument is compelling enough to disregard the results of trials studying particular treatments.
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Today's article is a guest post from Jason Eure, a physical therapist practicing in Virginia who likes to write a lot of words but doesn't usually share them. Personally, I am really glad he decided to put this post up here because he's a fantastic clinician and thinker who we can all learn something from. You can follow him on Twitter @jmeure
Internet discussions often remind me of the movie Groundhog Day. The theme may change (dry needling, manual therapy, posture, taping, etc) but the ensuing discussion will almost always follow a remarkably similar path. Invariably, the topic of expertise and its role in clinical decision making is weaved into the discussion to either argue for or against inclusion of certain treatment modalities. This point generally coincides with a “Sackett’s Stool” analogy where one party berates the opposition for being overly reliant on a single information source for guidance when it comes to practice, quickly followed by an equally condescending retort regarding the uselessness of expertise to provide reliable data. Both parties likely exit the conversation with bolstered perceptions of their pre-existing beliefs, and I’m left disappointed in myself for reading another thread with the hope that it may be different than the norm. This stereotyped discussion above is a mine-field of topics to explore; however, I want to tackle the interplay between research, experience, and values.
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Patients should unambiguously be at the center of our care. This is not up for debate and hopefully not a controversial idea. However, I continue to observe the manufacturing of a false dichotomy in which embracing evidence based practice and science somehow has to come at the expense of patient centeredness. Ensuring we are using the most effective and plausible interventions is fundamentally patient centered, because it is the patients who ultimately benefit from this. Having a strong foundation in science and research allows us to achieve this.
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Imagine a scenario where a patient comes into your clinic with a history of chronic ankle pain. This hypothetical patient has seen a handful of providers in her day, each with varying degrees of success — some relief here and there, but her ankle pain continues to return from time to time. You conduct your examination, identify a few concordant signs, rule out any serious pathology and begin discussing your plan of care.
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