Where physiotherapy gets logical
Evidence-based zealots, robotic clinicians, animated youtube videos of physical therapists turning patients away due to lack of support from randomized controlled trials — There are numerous examples, said in different ways, but ultimately the message is the same. Physical therapists, in hopes of being evidence-based, become handcuffed by research and in doing so lose their ability to empathize and stymy their flexibility in clinical reasoning.
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The idea of science based physiotherapy (adapted from the popular science based medicine) is a response to the notion that evidence based physiotherapy places too great an emphasis on comparative clinical studies at the expense of basic science. This is to say that evidence based physiotherapy undervalues, or even ignores aspects such as mechanisms, mechanistic reasoning and biological plausibility. This call for a greater emphasis on improving our mechanistic reasoning and our understanding of how and why we achieve the outcomes that we do is important. Sound mechanistic reasoning can improve the manner in which we research and deliver interventions while helping rule out more far-fetched ideas prior to dedicating limited scientific resources to them. This is because it encourages us to ask the question “are we confident that this treatment aligns with current knowledge of biology, physiology and physics?” As with all things, of course, it is important to recognize the limitations of our mechanistic reasoning as means of justifying our treatments.
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I am someone who rarely feels compelled to offer my unsolicited advice in a public forum. Therefore, it may seem strange that I am writing for the second time on the issue of intra-professional communication. Despite my desire to remain an impartial observer of the world surrounding me, an unnerving theme persists and motivates my interjection. In many ways, we fail to engage in constructive dialogues regarding professional topics.
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Here's another guest post from Jason Eure, who is still a pretty smart dude whose thoughts are worth your time. Follow him on twitter @jmeure
February 3, 2003: Adam Vinatieri lines up to kick a potential game-winning 48 yard field goal to win the Super Bowl for the New England Patriots. The snap and hold go smoothly, the kick is up and on line… but just as it’s about to sail through the uprights, a St. Louis Rams fan pushes the goalposts back 20 yards and the ball falls short: leaving the Patriots to lose in overtime (or at least I wish this above scenario had happened…I view my happiness as inversely proportional to the number of rings in Tom Brady’s possession).
While we (sadly) can’t influence physical goalposts to this extent, this happens metaphorically during many arguments — evidential standards are arbitrarily altered in order to make a counter-argument inadequate or insufficient. This is an informal fallacy known as (wait for it) ... shifting the goalposts.
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If a patient comes into a clinic, naive to the incredible benefits of Therapeutic Cabbage Rubbing and a physical therapist proceeds to sell them on how truly remarkable cabbage is, informing them of the unique resonance the cabbage creates when rubbed on skin, the science-y neurophysiological effects and stories of the success other people have had with the treatment from a position of assumed knowledge with obvious charisma — That patient might actually leave the clinic feeling a little better and be more likely to seek out therapeutic cabbage rubbing in the future.
Now say they walk into your clinic and as a well informed physical therapist, you know that therapeutic cabbage rubbing has no basis in our current understanding of physiology and lacks clinical evidence to support its efficacy and effectiveness, but this patient REALLY expects that the cabbage will help them out — does this expectation all of a sudden make Therapeutic Cabbage Rubbing a well reasoned treatment option?
No.
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