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Can we truly be ‘evidence-based’ physiotherapists?

Physio treating a patient

Including my training I am now in my 21st year as a physiotherapist and, over the past few years, the landscape of physiotherapy has been changing. Back when I trained we were taught a very biomechanical model of injury, based on many ‘theories’ which, over the years, have systematically shown to be incorrect through various bits of research – or perhaps not quite as straightforward as we first thought.

The approach back then was pretty straightforward: you stress something (perhaps a joint or a muscle) maybe a bit too much (overload/overuse) or in a ‘funny way’ (biomechanical ‘abnormalities’) or traumatically – and this leads to tissue damage. The tissue damage was then encouraged to heal ‘faster’ or more efficiently (eg frictions to align scar tissue) by the treatments we applied.

The treatment was supported by exercises that we prescribed to reinforce the effects from treatments that we had carried out in the sessions to get ‘carried over’ to the next session. This allowed us to progress the treatment further each time. A simple model that was relatively easy to apply but with one major flaw: it did not account for the complexities of individual people – taking a holistic view.

I first became a physiotherapist as I wanted to be able to help people. That has been, is, and always will be, my main motivator for doing what I do. There’s no better feeling than taking someone from the early stages of an injury and guiding them back to achieving their goals – this is what gets me out of bed most mornings (though sometimes it is my three year old!).

However, early on in my career it became apparent that, occasionally, there are people who, no matter how hard I tried, I just could not help. This was very disheartening as a young newly qualified physio who felt they could and should be able to help everyone. What was I not doing? What was I doing wrong? Most physios would pride themselves in being great problem solvers – so I have over the years tried to answer these questions and solve the problems of why for some patients my treatment/advice just didn’t cut it.

It’s been a long (and often winding) path along the way and I still feel my journey has a long way to go, but with changes in how we think about injury and pain, I have started to be able to look differently at how I practice and hopefully be able to change for the better.

Our understanding of the relationship between pain and injury has been evolving. We as a profession are realising that every person that walks through our door looking for our help is a little bit more complex than just a ‘pulled muscle’ or an ‘irritated tendon’. Most of the profession (there are unfortunately still some stuck in the old ways) now appreciates that the way we think about our problems massively impacts on how well we will recover – irrespective of what we actually decided to do to them as ‘treatment’.

During our training we have it drummed in to us that we need to provide assessments and treatments that are evidence based. But what is evidence based, what qualifies something as being evidence based?

This is where things get tricky.

A randomised controlled trial (RCT), was when I was training, seen as the highest level of evidence. In a study like this, patients were matched and then randomly assigned to groups who either received the studied intervention or did not. There are many issues with the methodologies of RCTs:

  • Accuracy of matching patients
  • Blinded/non-blinded treatment
  • Validity of outcome measures used to measure the effectiveness of treatment
  • The length of follow up in the RCT
  • Publication bias

In the late 90’s, a way of pooling similar good quality RCT’s to increase the strength of the results was beginning to emerge. This was called a Systematic Review (SR), which looks at all the research that has been carried out on a specific subject and whittles all the papers down to ones that are well carried out, good quality, RCT’s.

The results of these RCT’s are then pooled and statistically analysed again, creating one ‘study’ which statistically increases the ‘power’ of the results (much larger participant numbers). When you look at these SR’s you come to realise how difficult it is to undertake a ‘good quality’ RCT with researchers often finding hundreds of papers published on a subject and then only ending up with a handful that could be classed as ‘good quality’!

A model of a spine

There are several high-profile clinicians, who in their own way within the world of physiotherapy, are trying to wade through all the confusing ‘evidence’ to come up with their own interpretation of what constitutes best evidence-based practice. You may be surprised (or not) to hear that while there are things they agree on there is still a lot that they don’t!

So, you can see for a physiotherapist today it is hard to be ‘evidence based’! It may also surprise you to know that physiotherapists do not have ready access to all of this research. After recently reading ‘Black Box thinking’ by Matthew Syed (a great read if you are interested) it made me realise just how ridiculous this is!

Pilots have access to a global, central, incident reporting database. When an air crash happens, the Black Box data is analysed, and the results are then published on a central database. All the pilots in the world can see this and effectively learn from past mistakes. This has made aviation one of the safest industries in the world.

Nothing like this exists in physiotherapy – or medicine for that matter. Unlike medicine, the decisions a physiotherapist makes are generally not life or death. But they can certainly be life changing. You’d therefore think that any changes to evidence that would ultimately change practice would be easily disseminated among the physiotherapy community. Unfortunately, this is not the case. I can only hope in my lifetime that we do one day establish a central ‘database’ for all clinicians to access to help us all stay up to date and ‘evidence based’.


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