Physiotherapy: Are we at an ontological check mate?

 

In the next couple of days, I’ll be hosting the next Physio CPD Revolution. It will be our 1^stbirthday and I hope to be celebrating in the usual way of drinking anxiety inhibiting beverages and engaging in (often deep) discussion about alternative topics in physiotherapy such as philosophy and anthropology rather than the usual biomechanical, reductive, passive based professional development. You know the ones where we (clinicians) hope to cure through the conjuring of exotic spells (our confirmation biases) and the application of scented potions (massage creams).

So, this blog is about some deeper thoughts I have had about the identity of the physiotherapy profession.  I should start by saying that I am not speaking for the profession, these are my thoughts. I am also not speaking for other disciplines within the profession such as cardio and respiratory.  I can only reflect and share about my thoughts in the area I have spent all of my career, musculoskeletal (MSK) and pain management. 

My thoughts on where MSK physiotherapy is as a discipline have bounced around like pong* on steroids over the last couple of months, but have recently become consolidated into a malleable blob of clay ready to be moulded into… well something.

A recent listen to Cory Blickenstaff’s and Sandy Hilton’s Pain Science and Sensibility Podcast was the agent (the potter’s wheel if you like) to begin moulding my consolidated thoughts. Cory and Sandy were discussing a paper on expectancy violation (here) and its dissemination into Physiotherapy practice (this blog has nothing really to do with the content of the paper). Cory mentioned that the evidence in the paper had not been replicated in physiotherapy practice and at best we were extrapolating the information into physiotherapy.  My thoughts to this were several but the main question was, “considering we extrapolate and make assumptions all the time (and we tend to make extrapolations and assumptions from much of the research that circulates around the fringes of physiotherapy – strength and conditioning, exercise physiology, (more recently) psychology, OT, diagnostic imaging in physiotherapy is it really necessary?” Meaning is it necessary to always replicate research from one field to another?

Let’s not start digging out the hay bales and dungarees just yet! I’m not saying evidence isn’t important! My quandaries are many. Is there a need to replicate studies from one discipline to another when a) we are expected to advocate interdisciplinary working b) we have adopted a biopsychosocial perspective c) the person that sees the Psych, OT, PT etc is still the same person with the same concerns, meaning we have a duty towards shared decision making d) current research practice resembles that of the horse before the cart focusing on the justification of intervention rather than on patient outcomes.

Evidence based medicine has been described as ‘a loaded gun at clinician’s heads. “You better do as the evidence says,” it hisses, leaving no room for discretion or judgement’ (Spence, 2014), and that ‘evidence based medicine has not resolved the problems it set out to address that ‘healthcare’s complex economic, political, technological and commercial context has tended to steer the evidence based agenda towards populations, statistics, risk, and spurious certainty’ (Greenhalgh et al., 2014).

If we are to work interprofessionally and collaboratively why do we continue to conduct research reductively? Does this need for justification of our need to belong place us into an ontological check mate?

To adopt the kind of rigor that our current research methodologies advocate, does it mean we must adopt the same rigor for every aspect of our clinical practice? Considering nuance will always occur in our interactions with people at the clinical frontline, how far down the research rabbit hole do we want to go?

Having read the odd book chapter (Kerry, 2018) and the odd research paper (Fletcher et al., 2016; Hansen & Jones, 2017) there are advocates within academia that are advancing research to embrace ‘real-world’ trials, understanding the complexity of causality and the interactions of person agency and social context.

I wonder what this means for the future of research? It will most likely mean we direct research methodology to the individual patient, but will it allow consolidation of evidence across disciplines to provide a broader, nuanced approach to collaborative person centred health? And if it does, we will need sufficient critical appraisal skills to boot!

And

what will it mean for the future of physiotherapy?

Thanks for having a read

TNP

 

*Pong was one of the earliest arcade games

 

References

Fletcher, A., Jamal, F., Moore, G., Evans, R. E., Murphy, S., & Bonell, C. (2016). Realist complex intervention science: Applying realist principles across all phases of the Medical Research Council framework for developing and evaluating complex interventions. Evaluation. https://doi.org/10.1177/1356389016652743

Greenhalgh, T., Howick, J., Maskrey, N., Brassey, J., Burch, D., Burton, M., … Spence, D. (2014). Evidence based medicine: A movement in crisis? BMJ (Online), 348(June), 1–7. https://doi.org/10.1136/bmj.g3725

Hansen, A. B. G., & Jones, A. (2017). Advancing “real-world” trials that take account of social context and human volition. Trials. https://doi.org/10.1186/s13063-017-2286-8

Kerry, R. (2018). Reconceptualising causation in evidence- based physiotherapy. In B. E. Gibson, D. A. Nicholls, J. Setchell, & K. S. Groven (Eds.), Manipulating practices: A critical physiotherapy reader(1st Editio). Cappelen Damm Akademisk.

Spence, D. (2014). Evidence based medicine is broken. Bmj, 348(jan03 1), g22–g22. https://doi.org/10.1136/bmj.g22