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.
This idea, the worship of randomized controlled trials, a blinding of clinical practice by devout adherence to evidence, can be thought of as scientism: “An exaggerated trust in the efficacy of the methods of natural science applied to all areas of investigation.” Massimo Piuglucci provides a good primer on scientism, its pitfalls, and several popular figures who display characteristics of scientism here — The Problem with Scientism
But, does physical therapy have a problem with scientism? Does the profession have a meaningful contingent that rejects philosophy, the humanities, clinical experience, other other forms of inquiry outright? I’ve touched on this idea before, the notion of being “too evidenced-based” and clearly I think the answer is no. Research looking at physical therapists adherence to clinical practice guidelines seems to support this:
Simmonds et al found that only 12% (13 PTs) of the 108 PTs surveyed were able to identify clinical practice guidelines for LBP
In clinicians who were board certified in orthopedics and fellowship trained, a little over half (55%) were adherent to all clinical practice guidelines (Ladeira et al)
Joshua Zadro presented data that only about 35% of physiotherapy can be considered high value (defined as treating according to guidelines or providing at least one intervention recommended in guidelines or shown to be effective in a systematic review)
Physical therapy as a profession seems to struggle with following published guidelines. With this in mind, it seems that finding a clinician who rigidly treats in accordance with randomized controlled trials is fairly unlikely. Why then, if you read any twitter debate about the effectiveness of one treatment or another, is it inevitable that you find someone making the strawman argument of physical therapists of being blinded by evidence? Well, it’s complex, but largely it seems to be an artifact of human reasoning.
Most people are familiar with confirmation bias, or as Hugo Mercier and Dan Sperber prefer it, myside bias. This is the idea that people are more likely to seek out and be more agreeable to information that conforms to a prior opinion or belief. As Kolbert writes “Presented with someone else’s argument, we’re quite adept at spotting the weaknesses. Almost invariably, the positions we’re blind about are our own.”
Myside bias can be seen regularly in debates on physical therapy interventions. It is highly unlikely that someone will be called out for being an evidence-based zealot while highlighting trials that portray an intervention or the profession in a positive light. In other words, you’ll rarely get a disparaging tweet for being too evidence-based when presenting research that strength training reduces the risk of falls in an aging population.
This is because most of the time, positive trials are attractive to physical therapists. They validate the profession’s worth, they appeal to the clinician’s desire to help, and people are far more likely to recall their positive clinical experiences than their negative ones. So often, these positive trials coincide well with people’s previously held beliefs.
The strawman idea of scientism in physical therapy only comes about when negative evidence is presented regarding a cherished intervention. Look no further than a debate on manual therapy, dry needling, or any other contentious modality for examples of this. When negative evidence for a treatment is introduced to someone with strong beliefs to the contrary, this sets off a few alarms and creates significant cognitive dissonance for several reasons.
Often times, physical therapists identify themselves with particular interventions used. This can be seen in the popular manual therapist title or the proud letters displayed after someone’s name after the completion of a particular course. With this identity comes a sense of community, as people begin to associate with other self-identified manual therapists or any other clinical group.
Even further, clinicians want to help those seeking their care. They might see certain treatments work in the clinic, and then a few trials come along that contradict this. Due to that fact clinicians can sometimes calibrate their professional self-worth by their clinical success, this refutation of their experience can be difficult to reconcile.
So when a negative trial is shown that challenges beliefs, contradicts experience, and threatens identity, it is no wonder that people are more likely to double down on their beliefs and be highly averse to contradictory evidence, often with an eye-roll and a tweet about evidence-based zealots.
A few things are clear though,
Physical therapists (and healthcare providers in general) do not seem to blindly adhere to evidence, follow clinical practice guidelines religiously, or even show a solid understanding of what evidence-based practice is. At least in no way to the extent where scientism can be identified as significant problem in physical therapy writ large.
Over-treatment in healthcare, however, is very much a problem, with the costs of musculoskeletal related pain and disability continuing to climb. Evidence based practice gives us the best chance at knowing, on average, what works, and what does not, for individuals seeking care. Ineffective conservative care does not exist in a vacuum and providing less invasive and less risky, but equally ineffective treatments does not do anyone any favors.
And, unfortunately, many interventions directed towards addressing musculoskeletal pain and disability are underwhelming or do not work at all. This is true for both conservative interventions available to physical therapists, and more risky and costly interventions available to medical and surgical colleagues. So, it should not be a surprise when our favorite intervention fails to show a meaningful result in a published trial. Rather, as Archie Cochrane wrote, “[O]ne should...be delightfully surprised when any treatment at all is effective, and always assume that a treatment is ineffective unless there is evidence to the contrary.”
Physical therapists (and healthcare professionals, in general) would do well to develop a culture that accepts being wrong as something that is okay. Medical knowledge is constantly evolving and being wrong presents an opportunity to be better. Disassociating identities from interventions can limit averseness to being wrong, promote agility in clinical practice, and improve the ability to abandon ineffective practices and adopt more sound practices. Improving understanding and application of evidence-based practice (and yes, this understanding should include the limitations of evidence-based practice) will elevate the profession and better meet the needs of those who seek the care of a physical therapist. There are numerous problems in physical therapy that are worth discussing and addressing, scientism, however, does not seem to be one of them.