The Evidence on Evidence-Based Practice

There’s a funny underlying double-standard that exists when conversations arise accusing someone of not playing along with all the thrills & frills of Evidence-Based Practice.

While EBP apologists continually point out the lack of evidence for applying certain techniques and approaches, there is a distinct lack of self-awareness on the porous nature of the majority of medical (& physical therapy?) evidence. In case you missed it, the Editor-in-Chief of The Lancet recently stated,

Much of the scientific literature, perhaps half, may simply be untrue. Afflicted by studies with small sample sizes, tiny effects, invalid exploratory analyses, and flagrant conflicts of interest, together with an obsession for pursuing fashionable trends of dubious importance, science has taken a turn towards darkness.

And, Dr. Marcia Angell, who served for more that 2 decades as the Editor-in-Chief of the New England Journal of Medicine says,

It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines.

Nevertheless, EBP apologists make little haste using words like “woo” and “quackery” with supreme confidence. Does EBP exclude “quackery”? Don’t be so supremely confident of that.

The boundaries between quackery and EBM that clinicians are faced with are not so clear-cut. There is a need for doctors to acknowledge their share in quackery…

Let’s not forget the publication bias toward positive results. We hardly see the ones that didn’t work out. At least some steps to limit this massive bias have been taken. 

Odds are that you’ve already seen this important TED Talk by Ben Goldacre (his fantastic website is a must-read), but in case you haven’t, here’s your chance! The biases, tendencies, and habits mentioned apply across the healthcare spectrum.

Given that up to HALF of all published medical literature could very well be flawed, does it have strong legal standing? Well, not quite.

Evidence-based medicine and the use of CPGs won’t protect patients or physicians from all undesired outcomes or lawsuits, though they can be helpful in defense. They can guide decision-making, but can’t replace experience and judgment.

What about the applicability of published evidence? As Trisha Greenhalgh & company says,

The patient with a single condition that maps unproblematically to a single evidence-based guideline is becoming a rarity.

Well, there you have it. The “E” in EBP doesn’t translate efficiently into the clinic, will not protect you in lawsuits, and has it’s own inherent (even worse, hidden) biases. On top of that, it could make you delusionally overconfident, despite at least 50% of it being false.

What are the odds of these massive gaps existing in Physical Therapy’s published literature? Considering the severe lack of study reproductions, I’d say it’s very high.

If Evidence-Based Practice were a set of clothing you’re wearing, then you’d be no less than half naked.

Look here, here, and here for a few ideas on how to work with the inefficiencies of the “Evidence” in EBP and guide your practice perspective.

– @Cinema_Air


Image Source: http://www.4sportboston.com/2010/03/the-girlfriendwife%E2%80%99s-guide-to-march-madness-a-sports-nut%E2%80%99s-month-long-holiday/

Why Physical Therapists Need Physical Therapy

I wrote a guest post for Dr. Erson Religioso, DPT on Why Physical Therapists Need Physical Therapy. Here’s a preview:

Until recently, I didn’t consider seeing a fellow Physio for any other reason than necessity – pain, injury, etc. However, curiosity got the best of me, and I signed up for a few PT sessions and learned more than I expected. Here are my Top 5 Lessons so far.

Prima – every physio should know what it’s like to be a patient. Let’s drop the fact that you are a physio and might quietly (or not!) critique your care. View it purely from the perspective of a patient looking to return to full function: running, walking, sex, lifting, etc.

Here’s how Jill Baugh put it: “Only way to know if we get good care is to know if we get good care.

[Continue reading….]

5 Lessons Physical Therapists can Learn from Bruce Lee

I wrote a guest post for Strive Labs. Check it out:

“Bruce Lee is one of my personal heroes. While there are many reasons I admire him, I find his philosophical approach to everything the most salient and magnetic feature of admiration. We can learn numerous lessons from his life. Here are 5 lessons that apply to Physical Therapists as individuals, and Physical Therapy as a profession.”

Continue reading…

What’s so special about Physical Therapy?

When it comes to outpatient Orthopedic Physical Therapy, what does Physical Therapy offer that is intrinsically unique from other “overlapping” professions? I posed this question via a horribly worded tweet that lead to an interesting and very involved conversation. Check it out here.

Many of our treatment modalities are not confined to the domain of Physical Therapy, but are utilized by a broad spectrum of professionals. In terms of competitive advantages, exercise might be the weakest of our modalities. It has one obvious glaring shortcoming: the landscape of exercise is becoming flatter everyday. You can learn proper efficient exercise from any smart & experienced individual. They don’t have to be a Physical Therapist. They could be an athletic trainer, personal trainer, chiropractor…even your local gym rat. Information on exercise is becoming so ubiquitous that you could simply pull up a Youtube video to coach you through “corrective exercises”.

What about Ultrasounds & Electric Stimulation? Let’s put aside any knee-jerk reactions related to their effectiveness and think along the lines of Competitive Advantages. There is nothing stopping a chiropractor or athletic trainer from using these modalities. Even worse, utilizing these modalities requires a very short learning curve. Everything that involves binary decision-making combined with the potential for technological adoption will further flatten the competitive landscape and be vulnerable to outsourcing. Ultrasound & Electric Stimulation are no exceptions to this concept.

What about various joint & soft tissue mobilization techniques? The advantage will last only as long as the material is taught specifically only to Physical Therapists. Since Continuing Education is a capitalistic enterprise, these courses are usually offered beyond the confines of Physical Therapy. Therefore, any advantage conferred by these “techniques” is arbitraged against time. I believe Dry Needling fits under this umbrella. Once these “techniques” are utilized by other professionals, the advantage will moderate.

Is there any Evidence to “prove” our unique effectiveness as Physical Therapists? This article from 2001 was the only one brought to my attention. Notice that none of the main points are encouraging from an Outpatient Orthopedic point of view. According to the article, the only advantages conferred by being a Physical Therapist lies in niches.

Speaking of evidence, more evidence doesn’t mean more effectiveness. It simply means “more evidence”. The data is democratic, and the evidence can be applied by anyone of any profession, regardless of who did the research and produced the evidence. Simply because we may claim to be the profession that produces a sizable amount of neuro-musculoskeletal research, that doesn’t mean it is applied exclusively within our domain. Evidence has a level of promiscuity that should be appreciated.

The twitter thread mentioned earlier turned into an octopus and grew in different directions. This one was interesting because it eventually hit on something I had in mind. It’s about the Framework of approach that might be unique to Physical Therapy.

According to Tim, our uniqueness lies in our integrative framework to address functional deficits of any individual. Based on this perspective, Physical Therapy isn’t about “what” we do as much as it is about “how” we do what we do. While this sounds powerful (which it is!), the tricky part of it is the variety of philosophies & approaches within the profession don’t seamlessly lend themselves to a unifying framework. Other professions also view themselves as systems that incorporate different perspectives into a Plan of Care. After all, “integrative” is quite the catch-phrase these days. A unique & integrative framework will only remain a unique advantage as long as the process to understanding and utilizing the framework requires substantial achievement and effort. Once these hurdles are either lowered or removed there will no longer be a unique value proposition.

Even worse, here’s what the research says about perception of Rehabilitation Professionals:

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So, we don’t “own” any treatment modality, and we don’t have evidence to back up our unique effectiveness. Are we in a rat race against “sameness”? Back to the initial question:

What’s so special about Orthopedic Physical Therapy?

What are your thoughts?

@Cinema_Air

P.S. – There was a #solvePT discussion that revolved around the central concept of the post you just read. Check it out here.


For Further Reading:

  1. http://www.evidenceinmotion.com/blog/2014/03/24/what-differentiates-physical-therapy/
  2. http://www.evidenceinmotion.com/blog/2014/03/16/trigger-point-dry-needling-tdn-is-not-physicaltherapy/