Rehab and Medical Practitioners across the world dedicate their weekend, time and salary to the pursuit of learning new skills, knowledge and research so that they may help people.
Why? Probably because we all feel the need to improve ourselves, give a better service, continually strive to be the best, or just because a governing body enforces CPD upon us.
In these conferences, courses and seminars, dedicated professionals listen avidly to the ‘expert’ delivering the content. These Avatars of rehab can leave some of the audience the feeling that their new found approaches and techniques are the best thing since sliced bread and they encourage an enthusiastic venture with these new techniques to the detriment of previously used methods. I’m sure you are reading this article recounting the electrotherapy you learnt at university, the ‘core stability’ that was hailed as the cure for all things including gingivitis and leprosy and then there are the magician manipulators or acupuncturists.
These are simply different paradigms: A set of ideas or beliefs held within the mind.
And I wonder….. Are we actually making people healthier than we used to?
Is the long term outcome of manipulative therapies better than electrotherapy?
Are people getting fitter than they were? Are people recovering from injury any quicker?
Is the prevalence of LBP any different to the good old days of electrotherapy or the sports ‘physio’ with the magic sponge?
There have been countless research articles that compare the various approaches to healing within physiotherapy and unless the research is carried out by a person/persons who are promoting their own approach, the results show very little difference between modalities/beliefs (1,2,3,4,5,6).
Are we making people healthier?
Core stability had been researched extensively in chronic low back pain and was found to be an effective evidence-based practice. Then, some of the very people who had been championing its success changed their paradigm and produced other research that disproved it. How much can we trust the ‘evidence’, most of which wouldn’t even make it into a Cochrane review?
What can we do to stop ourselves being drawn into every new paradigm or ‘fad’ like a hypnotised flock of sheep?
There have been paradigms all through medicine, and there will be more in the future. If you want evidence of this, you need only consider the history of our great profession. Kuhn (7) presented his theory of scientific revolution, and Hewa (8) argues that the development of Western medicine from Hippocrates to the present has involved a revolutionary change in paradigms, causing pre-existing beliefs to be thrown out with the bathwater to help better explain current health problems. Hippocrates argued that ‘walking is man’s best medicine’ and it seems he was right, although this era of medicine also saw a belief that health was related to the 4 humors; an imbalance of the principle fluids within the body which were, yellow bile, black bile, phlegm and blood.
This changed in the Middle Ages when health became an extension of our religious beliefs, where a disease was considered a form of punishment or a test of faith.
The renaissance period brought with it a previously unknown level of literacy with the printing of new innovative, or ‘anarchistic’ views spreading through the western world with access to previous theories on health and ‘medicine’. This brought with it the ‘enlightenment’, or ‘age of reason’ which included the work of many scientific thinkers such as Francis Bacon & Renee Descartes (16 – 17th Century) and Isaac Newton (17 – 18thcentury). With this came careful observations, systematic collection of data and mathematical reasoning, which we still embrace today.
This practice applied to the study of medicine and surgery. Remember that surgery had morphed from barbers who would perform small procedures in their barber shops. Be cautious when speaking poorly of another person’s paradigm or professional modalities started somewhere!
“ Are we making people healthier? ”
This period of enlightenment bred the Biomedical Model of Health that created the science of bacteriology (Louis Pasteur) and the science of cellular abnormality. It is still used today. A few interesting observations for the health, fitness or the medical industry of today and perhaps a lesson.
Are we transitioning into another paradigm when one considers that these models/theories are simply a reflection of the people who create them?
Are we performing research on methods that exist within their beliefs rather than paradigms and modalities that exist outside the realm of our own practice?
Are we at risk of becoming a profession that resembles a self-licking lollipop that serves to prove its own self-worth?
Sound harsh? This may explain why so many previously ‘proven’ treatment modalities have later been overshadowed by a different author who carries out research with slightly different statistics or methodology (9). Hence the lack of consensus within physiotherapy when it comes to best practice pathways.
Within research, can we simply manipulate statistics, methodology and results to provide evidence for our own personal agenda?
To consider the best practice pathways that support a paradigm can also have other drawbacks. Such models can lead to a dangerous oversimplification or misrepresentation of reality, reducing a complex process to a simpler one (9). This can be seen with best practice pathways for tendon injury for example. Treatment can revolve around techniques that have been evidence-based without considering other techniques that might not have yet have been researched, either because no one has attempted to, or because the benefits are so clear to see that no one has challenged them. Perhaps a given modality has been overshadowed in a poor quality research paper in the past? Even if there is no good evidence to dismiss a certain modality, mud sticks and rumours travel fast.
The Alfredson eccentric loading program was once the gold standard and better than concentric or isometric. In fact, I remember there being a significant judgement within our profession for anyone that dared to use anything other than eccentric exercises. Look where we are now. A new person with a different agenda appears with different research to suggest that isometric exercises are great for tendon pain instead of eccentric, especially in acute management.
The same can be said for core stability. Smith et al (10) completed a systematic review with meta-analysis confirming that core stability is no more effective than any other general exercise programs. I remember a time where one might be judged for not teaching transverse abdominus and core stability for all conditions from neck pain to ankle instability. There has been a growing consensus for nearly a decade that this paradigm may be detrimental for LBP sufferers and this change in heart has been supported by one of the original pioneer of core stability, Peter O’Sullivan who now does great work promoting an acknowledgement of a different paradigm in the biopsychosocial model. What must be remembered is that these findings on core stability are specific to people with ‘chronic non-specific low back pain’ only! Given a screening for psychosocial issues such as a Start Back, the core stability paradigm may still be an effective treatment modality (no worse than other modalities). It is a question of clinically reasoning the use of treatment rather than just treating all patients the same.
So be careful when laying your hat and faith in the current paradigm of medicine that encourages only the ‘evidence based’ treatments without space for well-reasoned and anecdotally successful treatments. This history also teaches us not to judge others with a different paradigm to our own!
‘Blind Faith in authority is the real enemy of truth.’ Albert Einstein.
Additionally, these evidence-based findings often revolve around the Biomedical Model which assumes that all pain must be derived from one physical source and The evidence does not support this.
The Biomedical Model assumes that all pain must be derived from one physical source and the evidence does not support this.
We are entering a new era of medicine where we are increasingly embracing the Biopsychosocial model, which in some ways can be in direct conflict with the Biomedical model.
This can be seen in the once-held view that pain is caused by a disc bulge, a cartilage lesion, a ligament tear, a cam deformity. The very same scientific values that brought the ‘age of reason’ has also lead us to question our beliefs as we increasingly investigate these structural deformities in healthy fit asymptomatic cohorts and find that they are just as prevalent (11,12,13)!
So all of a sudden, a disc bulge or a positive pressure testing for compartment syndrome or a positive blood test for rheumatoid arthritis become ‘so-what’? The disc bulge can now be seen as a normal age-related change, just like grey hair. You don’t see people develop headaches just because they go grey or bald!
So we are forced to look outside of the box to find an answer to the problem, all the while probably just moving to the next paradigm that will then be replaced somewhere down the line.
Specifically, within fitness and rehab, we are riddled with paradigms from manual therapy, massage, acupuncture, electrotherapy, exercise therapy which itself has had many differing ways of operating and these paradigms can often move like the tide. It may be good to have many different techniques at our disposal to make a person in pain more comfortable or an athlete more powerful. It helps if their application is clinically reasoned, rather than treating every LBP patient with the same modalities as the last, just because it is ‘evidence based’ and part of a ‘best practice pathway’.
The ‘age of reason’ is very useful to remember in our own practice.
Just as we are challenging our generic beliefs on pain (11,12,13)
Are we challenging our specific beliefs about medicine with each patient?
Is everybody’s ‘core’ weak? Hamstrings short? Or do we just assume that because they have back pain?
Do we question our ‘observations’ and test the body to assess if the person’s core is even weak in the first place? Is the joint even stiff? Is the meridian blocked? If so, how is it weak? Where is it weak? In what positions is it weak? Does that patient have poor beliefs about pain? How do you measure your findings? Once you have delivered the more specific rehab program to your client, has their function changed? Has their pain changed? How have you measured this? How effective is your paradigm and your clinical reasoning?
There is one thing that I suggest you remember. The reason you were drawn to the medical or exercise profession, (side from the illusion that we might end up being the next England football physio, meet a handsome, wealthy doctor or be seen as an upstanding member of society) we want to help people.
Remember that when people come to us for help, they are also in a suggestible state. Be careful with your words. Use your words wisely to help heal people. Use the Placebo effect… it is not a dirty word. It is in everything we do, and as we move away from complete faith in the biomedical model, we have to accept that we can influence people with our words just as much as actions. Imagine taking an evidence-based rehab program and delivering it to a patient without any enthusiasm or conviction. How effective do you think that program will be?
If you make a person feel comforted, cared for and can allow them to believe that you can help them, then there is a good chance that you are already halfway there. Does it matter whether we use acupuncture, electrotherapy, manual therapy, massage, S&C, Yoga? Our ego might believe this, but I’m not sure the Cochrane library would support this view.
The ‘age of reason’ is very useful to remember in our own practice.
1. Helliwell .P.S, Abbott C.A, Chamberlain M.A (1996). A Randomised Trial of Three Different Physiotherapy Regimes in Ankylosing Spondylitis. Physiotherapy. 82(2):85 – 90.
2. Langhammer B, Stanghelle J.K (2000). Bobath or Motor Relearning Programme? A comparison of two different approaches of physiotherapy in stroke rehabilitation: a randomized controlled study. Clinical rehabilitation. 14(4):361 – 369.
3. Hawkes J, Care G, Dixon J.S, Bird H.A, Wright V. (1986) A comparison of three different physiotherapy treatments for rheumatoid arthritis of the hands. Physiotherapy practice. 2(4):155 – 160
4. David J, Modi S, Aluko A. A, Robertshw C, Farebrother J (1998). Chronic neck pain: a comparison of acupuncture treatment and physiotherapy. Rheumatology. 37(10):1118 – 1122
5. Hey E.M, Mullis R, Lewis M, Vohora K, Main C.J, Dziedzic K. S, Sim J, Lowe C. M, Croft P.R. (2005) Comparison of physical treatments versus a brief pain-management programme for back pain in primary care: a randomised clinical trial in physiotherapy practice. The Lancet 365(9476):2024 – 2030
6. Cherkin, D.C., Deyo R. A, Battié M, Street J, Barlow, W. 1998. A Comparison of Physical Therapy, Chiropractic Manipulation, and Provision of an Educational Booklet for the Treatment of Patients with Low Back Pain. New England Journal of Medicine.; 339:1021 – 1029.
7. Kuhn T.S The structure of scientific revolution 3rd edition. London:University of Chicago Press. 1996
8. Hewa S. The coming revolution in western medicine: A BioPsychoSocial model for medical practice. Int review of modern sociology. 1994. 24(1); 17
9. Russell L Sociology of health professionals. London: sage publications Ltd. 2014
10. Smith B.E, Littlewood C, May S. An update of stabilization exercises for LBP: A systematic review with meta-analysis. BMC Musculoskeletal disorders (online). 20013. 15(416): 1 – 21
11. Brinjikji W, Leutmer P.H, Comstock B, Bresnahan B.W, Chen L.E, Deyo R.A, Halabi S, Turner J.A, Avins A.L, James K, Wald J.T, Kallmes D.F, Jarvik J.G. Systematic literature review of imaging features of spinal gedeneration in asymptomatic populations. AJNRAmerican Journal of Neuroradiology. 2015. 36(4): 811 – 816
12. Chou R, Fu R, Carrino J.A, Deyo R.A. Imaging strategies for low-back pain” systematic review and meta-analysis. Lancet. 2009. 373(9662): 463 – 472
13. Anderson J.C. Is immediate imaging important in managing low back pain? Journal of athletic training. 2011. 46(1): 99 – 102
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