Physiotherapy has long been moving towards higher standards in research and better quality care. 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. You don’t want to be doing things until you can be sure that they will work.
But is that realistic? Is every intervention we make as physiotherapists and sports therapists definitely going to make things better. Those of you who have had treatment from any therapist before should know the honest answer is no.
Even the best piece of research might conclude that an intervention will reduce pain by 50% in 60% of cases. So how do we get this to reduce by 100% in 100% of cases. The honest is we can’t. We’re good, but we’re not God!
We prefer to look at individual evidence. What works for this person in front of us? We can create our own evidence that is much more relevant and important than any generic impersonal research.
That’s not to say we make stuff up as we go along, although, to certain degree this is true! The individual approach we take with each of our clients is based, as you would hope, on sound fundamental principles. We want to be ‘trying things out’ knowing that we’re not going to make it worse.
In this article we’ll look in a bit more detail at the pros and cons of evidence based physiotherapy and then outline how we tailor this evidence based approach to each individual client.
What Is Evidence Based Physiotherapy Practice?
“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).
But how do we apply this to organic emotional beings? We’re not computers dealing only in ones and zeros. We are all varying shades of grey. 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)
This seems very draconian and restrictive to me. It would certainly make for a boring day for therapists and clients alike at Brighton Physiotherapy & Sports Therapy! But what is “sufficient evidence”? Is noticing patterns from experience evidence? Is working as a therapeutic team to try things out and decide whether they work or not for the individual evidence?
What Is Physiotherapy Evidence?
Let us take one of our day to day favourite techniques as an example. A hip flexor activation. Many people come in to see us with hip flexor problem or equally we suspect their hip flexors (psoas) are affecting their bio-mechanics particularly common in low back and knee pain. We do a strength test before and a strength test after our treatment to assess the effect 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, a lot. Is this evidence?
Nay sayers will immediately site placebo effect. Which we talk about in depth in our previous article here. If it is placebo then I’m happy to use it! Generally speaking in medical research placebo works in about 30% of cases. We see a much higher success rate than that, even with people who aren’t convinced about it at the outset. All we ask is that you’re open to give it a try. And if you’re not, just let us know and we’ll do something different.
Now that’s not to say that we just do our hip flexor activation and that’s that. All your bodily concerns are resolved forever. But it gives us guidance for our tailored approach to your ongoing care.
If hip flexor activation has worked for you then we could look at how they got tight in the past. Possibly sitting with less than optimal posture for prolonged periods. Or possibly something more emotional like the physical representation of some old buried stress or trauma.
Either way it suggests to us that breathing exercises and paying more attention to posture could be good options for long term resolution of pain. These are just two examples. There are more. Hip flexor stretching could work for you. Changing your yoga practice, or introducing one might be a good option.
Perhaps even feeling an improvement in your symptoms by releasing an area that initially seems unrelated might reassure that the pain that you were feeling is not something ‘wrong’ with the joint, nerves, ligaments or tendons. This change in belief not only reduces the sensitisation of the nervous system to the issue is also helps you to move with more confidence and freedom. Which in turn changes your movement pattern which means you no longer feel the pain. Could this be considered evidence in a highly specific personalised case? I feel I want to say evidence is ‘proof is in the pudding!’
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.”
So 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 if they can get them to work for themselves and their clients to further understanding and create new and better ways to help people.
Why Look Beyond The Physiotherapy Research?
Firstly things can always be better. Secondly not all things work for all people, it’s just not possible. Thirdly the research itself would never move on if we didn’t! Theories in physics come a long time before experimental proof. Just ask Einstein and Newton.
If I have a technique that I’ve seen work every now and then with clients with a certain condition. Let’s say one in ten for argument sake. Am I going to use it? By strict research methods we probably shouldn’t. But if we help 1 on 10 people, and importantly the technique will not do any harm why wouldn’t we give it go?
Science is proof by elimination. Keep going until you find something that works. Generally at the clinic we start with the most obvious imbalance in the person in front of us, or the intervention we most commonly see positively influence the condition we are treating. If what we try works, great, that shapes our rehab and aftercare advice. If it doesn’t we move on to try the next most likely culprit.
This all does assume you believe, as we do, that pain isn’t simply because there is a problem where it hurts. Of course sometimes it is. But if the pain started without a specific injury, or the original injury is more then 6, maximum 12 weeks ago, we need to look holistically at the body as a whole to unwind the painful movement pattern and the sensitivity of the nervous system.
A more balanced outlook which sums things up quite nicely is from 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 scan had come back to confirm that she had acute nerve root compression she was pain free and climbing mountains in Wales!
If you’re interested in this idea that scans aren’t the be all and end all when it comes to diagnosis check out our previous article on MRI scans which contains great research showing how a multitude of scary sounding conditions exist in so many of us who have zero symptoms!
My favourite quote is from Stephen Hall from his book Wisdom: From Philosophy to Neuroscience which eloquently describes what it is to be a therapist:
“The ability to exercise good judgement in the face of imperfect knowledge. 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.”
I think world renowned pain scientist David Butler sums up the points I’m trying to make well when he says:
“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 On Evidence Based Physiotherapy
Whilst evidence is useful and an important part of what physiotherapists and sport therapists do we strongly believe that we shouldn’t limit ourselves by using only methodologies that have withstood the rigours of randomised controlled trials. Absolutely this evidence should influence and guide us but it is not the answer to everyone’s problem. It can’t be. If we only work with what has been categorically proven how do we evolve towards our next paradigm?
Surely science is about evolving theories and then coming up with ways to verify how accurate those theories are. On a day to day basis we ask after every intervention: “Is that the same or better.” If it’s better great, we have new valuable insight. If it’s the same, we move on. And chalk that possible culprit off our list.
This is a day to day example of how we modify and evolve our theories for the betterment of our clients. My plea here is to any therapist or prospective client is to 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 Brighton Physiotherapy & Sports Therapy we pride ourselves on bringing together all aspects of the latest physiotherapy research and adding in a mix of clinical expertise. If we have a technique that we think will work, we try it, and it works, is this not evidence?
Of course we can’t guarantee our approach will work for you which is why we recommend all prospective clients to request a call back from us so we can discuss your individual situation. We can give you a more detailed idea of what we would do for your condition and explain what you can expect from us. And if that doesn’t sound like what you need, try something different, but do keep trying.