Catherine Moore updated 6th Feb 2020
Physiotherapy has become a very confused profession. When I first qualified over two decades ago, life was very simple. Poor posture caused back pain and reduced core stability contributed. Agreed maybe it was a little too simplistic but lots of patients benefited from this wisdom. However, as the profession ‘grew up’ it wanted to be more accepted in the medical community for having an evidence base, so we went about proving that what we did was effective. We embarked on a journey towards truth that involved applying effectiveness research to everything we did. Because we wanted acceptance, we pursued the gold standard of evidence, the randomised control trial (RCT).
Funny fact about RCTs; they were designed to show the effectiveness of drugs.
Drug treatments can be blinded (so you can be given a bottle that might contain a drug or it might just contain a dummy tablet, no way to know hence the term blinding) and drugs can be dosed (the same volume of the drug can be delivered each time). In the Physio world the ‘drug’ is the treatment we offer. In order to decide upon that treatment there is a complex social interaction that goes on between the therapist and patient. An alliance is formed based on what the patient perceives will have benefit and the evidence/ experience brought by the therapist. The problem with this interaction is that it can neither be blinded or dosed.
The good Physio will take the time to explore the finer nuances of the patients’ problem. What aggravates the problem, what eases it, what functional limitations does the patient report. In many ways, patients are very similar but also very different. Take for example two back pain patients (please excuse the extreme stereotypes here). Mrs Jones is a nurse who stands or walks for 12 hours whilst Mr Smith is a brick layer who will bend forward most of the day. They both have back pain but their genetic make-up, body morphology, eating habits, exercise habits and other lifestyle factors mean that their tissues are under extremely different stresses. This brings me to the next issue with RCTs; in an RCT, both patients would be labelled “non-specific low back pain” (NSLBP) and given the same treatment. Currently the majority of low back patients (94-95%), regardless of the differences in stresses, will be labelled low back pain and researched in the same homogenous group.
The other thing the RCT requires is a control group or placebo. Control is really important in drug trials as the control group of the trial can be given a ‘placebo’ which is the dummy drug but patients won’t know they are receiving it. In physiotherapy trials the control is usually no intervention (patient remains on a waiting list) or usual care (GP and meds). Does the patient assigned to the control group then go and sit in a dark room for the whole time the other group are receiving the treatment in the trial? No of course not! They have access to friends, books, the internet, this blog. They will attempt to find answers and may even follow advice, so can they really be classed as a control in this instance? I do not believe so. These confounding variables can influence recovery.
Compare the two groups six months later and guess what? There is no discernible difference between the treatment group and the control. The conclusion is that the intervention is dismissed as ineffective. However, the problem here is that statistics have been used to show the difference between the groups. Statistics will tend to use the mean improvement scores from both groups and compare them against each other. Mean is the average improvement, average means average. Some people will have improved a lot, some people will have had a moderate improvement and some people will have worsened. When we average this out, we get a small or minimal change based on the intervention. What we don’t know is which patient improved and why or indeed which patients got worse and why? Maybe the intervention does work for the right person at the right time but due to the homogeneity of the researched group we can’t answer that question.
As a consequence of this over-reliance on the RCT, we have therapists who will tell you that the there is no evidence that how you sit makes a difference to your low back pain (it does but don’t tell anyone I told you), there is no evidence one exercise programme is better than another for low back pain (there are better ones but again please don’t tell anyone I told you this), there is no evidence that tape is useful (it is when used at the right time for the right purpose, but if you tell anyone I said that I might have to kill you). Where does this leave us as a profession and where does this leave the patient. If nothing works….do nothing? Sit how you like for as long as you like? Do whatever exercise you like or no exercise? The pain is all in your head and you just need to sort your head out? It has become so confusing.
Therapists have become dependent on the published evidence and have lost sight of the original tenets of the evidence-based triad. It is a balance of the best of the published evidence (I am inclined to argue that the RCT is not the best for Physiotherapy but that is my personal opinion), the evidence the patient brings and the evidence the therapist brings based on their expertise and experience. What the evidence from RCTs tell me is that what they show does not match my daily evidence gained through patient encounters. Does this mean I am wrong and the RCTs are right? My patients tell me otherwise. They tell me they feel better, move more, get back to their functions. Why is this so different to what the published ‘evidence’ says. Could it be the methodology of the research is wrong?
I am undosable
I am unblindable
I do not treat you all the same
I am not wanting to give an ‘average’ treatment
Here at Moore Associates every patient is an individual. We will look at the unique needs of all individuals. If you have to sit for work, then how you sit and how long you sit is important. If you need to walk, how you walk is important. If you must bend a lot, how you bend is important. We assess what will help your low back pain in relation to your genetics, your morphology, your lifestyle habits and tailor your rehab to the stresses your body needs to cope with. We will use tape if we think it is warranted, we will use massage, mobilisations and core stability when it is required to help you move and cope with your day to day activities. We will not give you a generic exercise sheet that will have as much chance of making you worse as helping you improve. We will teach you how to manage YOUR back – its yours so YOU need to manage it.