How often do we see a new paradigm break through the world of exercise and rehab with marketing and sensationalized hype? They sometimes break into our gyms, clinics and hospitals with little evidence of sound research. We are taught to insist upon a clear clinical reasoning that is followed up with research to objectively test the paradigm. But should we implement these paradigms or treatment within our profession before we read the research? I will go out on a limb. To hell with ‘Evidence based practice’. Sound harsh? Sound dangerous?
To hell with evidence based practice
Consider mirror therapy, which was initially a creative clinically reasoned treatment and now has a body of growing evidence for peripheral nerve injury and stroke. There may have been many skeptics of the practice before there was any research to support its use. Was it unethical to use prism glasses or a mirror box before there was research to support it?
What about all the people who were helped by the practise before it became ‘evidence based’? Would you deny them the treatment if you had the chance to treat them? I think it’s time to jump off the pedestal. If exercise professionals did not clinically reason new ideas that are ‘outside the box’ would there ever be new ideas and modalities to help people? Let’s remember, the ideas for research don’t come from research. They come from creative and innovative therapists and exercise professionals who step outside of the box in a clinical environment. Once popularity is gained, scientists conduct research.Are we otherwise at risk of standing still as a profession and only using the same treatments which are evidence based? We could end up with a profession that become a self licking lollypop, not allowing anything new into the party! What’s more, I don’t think exercise professionals were unsafe or unethical before the advent of ‘evidence based practice’?
If we only use evidence based methods, are we being unethical by refusing treatments that are known to be effective simply because they have not been researched? If there is conflicting research for a paradigm or treatment does this mean that we must not use a treatment technique since the evidence is confusing? How purist should we be about the use of ‘Evidence based practice’? Only use treatment techniques or methods that have been approved by the Cochrane review?
Interestingly, I wish you to explore your conscience. Is every specific manual treatment you use for the foot or ankle joint researched? Is every exercise you prescribe such as a deadlift researched for every condition that presents to you? I wonder how ‘evidence-based’ our practice is if we scrutinize it? So why do we hear such ‘chapter & verse’ within the medical and exercise profession about being ‘evidence-based’?
How can we maintain a balanced perspective
I was involved in a journal club today that had been organized by a colleague after attending a ‘running re-education’ course recently. She had found the course content to be outdated since forefoot, mid foot, prosthetic running re-education has been researched for nearly 10 years. The assessments used in the course seemed plucked out of the air, lacking any real reasoning or evidence. It seemed not to fit with any particular reasoning or rationale. Yet it was allegedly backed up with ‘research’.
The course seemed to base its beliefs on a research journal, which we later critiqued in our department journal club. The journal in question was a meta-analysis of how injuries are affected by different kinds of exercises. For those of you that are not well versed with research, that simply means that the authors gathered as many research papers that they could, to provide a summary of the evidence. This in itself is open to variation as two authors could read and interpret the same research paper in different ways. The Cochrane Library works on a similar principle yet is very strict on which articles it allows to be used in its collaborations.
The quality of the research is scrutinized to ensure only high quality journals are used to inform the Cochrane summary. Unfortunately, the Cochrane reviews on topics of rehab, exercise and musculoskeletal medicine don’t even get that far. This is because the research within musculoskeletal medicine and exercise often use poor methods or are untrustworthy with biased statistics. The Cochrane Library can not trust their findings. The risk and the danger as far as ‘evidence based-practice’ is concerned may be that exercise and medical professionals are incorrectly educated by research. So we must be careful how much faith we put in many of the journals or ‘best practice pathways’ that we use to underpin our work. If the journals have not made it into a Cochrane review, we must be careful of how attached we become to our own beliefs.
So how can we maintain a balanced perspective?
The particular meta-analysis that was used to underpin the running re-education course made many conclusions and it is very easy to be drawn into believing absolutely every conclusion made by a research paper without understanding, or applying the findings without reasoning. An example of this can be seen in the conclusions drawn from the evidence surrounding stretching/flexibility training. Most evidence on stretching is involved with pre-exercise stretching. There is very little evidence as to the effect of a long term stretching programs on strength, power, injury, muscle length etc. The meta-analysis in question insinuates that stretching of all kinds is not effective for running and injuries.
Is this short sighted? What about separate flexibility training sessions? Can they help and if so how? What evidence exists for long term flexibility training for injury and the performance of running?
Is it clinically effective In the form of yoga, fascial stretching, static or dynamic stretching? What if the evidence hasn’t captured such results?
Another danger of adhering to ‘best practice’ pathways and evidence-based guidelines is that it risks reducing a very complex process into an over-simplified ‘recipe’. For those physiotherapists who like to operate in ‘recipes’, there is a risk that an assessment can look for the signs, symptoms and objective tests to confirm that our recipe is correct, rather than assessing each knee as being different and in need of different management from the last client.
Should we ever allow ‘Evidence-based practice’ to stand in the way of sound clinical reasoning
On a personal note, I am always skeptical of listening to people that sell their beliefs by discrediting other approaches, and speak without detail or evidence. We have to consider the evidence by assessing its quality and the clinical reasoning we use when prescribing exercise or giving treatment.
To end on a philosophical note, I wonder whether we should ever allow ‘Evidence-based practice’ to stand in the way of sound clinical reasoning?
David is a Physiotherapist who has been involved in Professional Sport, battlefield trauma, chronic pain and the NHS. He continues to work clinically alongside his development role in Rehab Guru. David is passionate about Health tech to transform outcomes for patients