How To Cure Evidence B(i)ased Physiotherapy

For many years I laboured as a physiotherapist under the illusion that my work was a scientific pursuit, one hundred percent dependent upon research – and nothing else. There was little room in my clinical reasoning for fluff and woolly thinking.

I had early longings to be a ‘Maitland practitioner’ and was crestfallen to say the least when I realised pretty quickly that all was not what it seemed e.g. joints don’t – can’t! – move when you push on them and patients had emotional lives that often got in the way of their treatment – to name but two of the dawning realisations. There were many, many more (I can’t bring myself to mention short wave diathermy).

I probably ‘ran for cover’ from the incoming fire. My clinical world gradually morphed into one of black-and-white ‘facts’ gleaned from arcane tables landscaped in early editions of Manual Therapy.

I could now be found handing out reams of questionnaires to patients, ‘ratifying’ only those ‘management pathways’ that were ‘supported by the evidence’; I was undertaking a mini-research project on every single individual I saw. I fought to exclude any and all confounders that might interfere with treatment outcomes. This was, in no uncertain terms – clinical work.

Then one day, I hit the buffers.

I remember it vividly. I had been referred for treatment an individual, let’s call him ‘Harry’, who was experiencing profound problems following a whiplash type injury:  he was suffering from vertigo, dizziness and high levels of pain. He was unable to continue managing his own –  up until the time of the injury –   successful IT business.

As I have mentioned my custom was to embellish the usual musculoskeletal physiotherapy assessment with a flourish of four or five questionnaires screening for post-traumatic stress responses, catastrophisation, fear of movement, central sensitisation and neuropathic pain: psychosocial factors having been identified as strong predictors of poor outcome following whiplash trauma.

I remember thinking at the time that the consultation had gone quite well and of course I was feeling quite proud of myself because Harry had seen several clinicians – including for medicolegal purposes – and none had screened for these kinds of psychosocial factors in such depth.

The problem was…..Harry never came back to see me.

I emailed the solicitor who referred Harry to me and was shocked at his reply: ‘Harry felt overwhelmed by the questionnaires you gave him.’

Overwhelmed? What ?! There must have been some misunderstanding, I was trying to establish where Harry was with reference to the research literature. I was trying to determine which sub group he was in, so that I could insert him into the appropriate evidence based pathway.

But Harry – the person – didn’t want to know and in fact I had overlooked him completely. I was literally blinded by science, to the extent that I could not even see Harry.

There had been hints along the way that perhaps this approach that I was adopting had its limitations. Individuals who came to see me for help with their pain would often remark as I handed them a stack of questionnaires and they duly completed their psychosocial matriculation exam: ‘this question doesn’t really apply to me…’ or ‘this question asks about pain…it’s not really a pain it is more of an ache…’ I would nod and smile knowingly whilst at the same time worrying what possible effect their ‘missing data’ would have on the internal validity of the blessed questionnaire!

And in my teaching I had confidently batted aside any suggestions that this evidence based approach I had adopted had shortcomings. Clinicians would challenge me ‘isn’t there a risk you’re pathologising people here?’ or ‘this is quite a scary list of questions for any patient..’ Again, I knew best. There was for me ‘The Evidence’, and no other light to guide me.

But after the Harry episode I slowly came to the realisation that something was missing. I had lost my way. Things were going to have to change.

Of course I knew about the three circles of Evidence Based Medicine. Of course I knew about patient preferences, and clinical expertise. So what had happened?

It was clear: the ‘best research evidence’ had taken more than centre stage in my work. It was standing between me and the patient, blocking my view. There was a long dark shadow in my clinic room.

Looking back I could see that my early and deep disappointment in Maitland-style gurus and their unfounded belief systems had caused a major shift in my thinking and clinical activity. I had moved away from ‘clinical expertise’ and I developed a distrust of my very own senses. I had moved away from the preferences, values and the story of the person I was tasked with helping.

In fact, the very things that research attempts to exclude from it’s computations were the very same things I needed to start including: work, home, the past, feelings, emotions, thoughts, family, stress, pleasure, desires, plans…it is after all these things that make us ill and it is these very same things that can make us well. Not how far you can bend your back or how high you can lift your arm!

I had fallen into the very trap that the pioneers of evidence-based medicine had warned against: my practice had become well and truly ‘tyrannised by the evidence’ (Sackett et al 1996).

Something had at last ‘clicked’ and thus I journeyed slow, but very slow…..from the ‘laboratory’….to the ‘jungle’. In the words of the great William Osler I had now started to treat the person who had the disease, rather than the disease.

I could now see that I had seriously erred but with this epiphany came the realisation of a powerful but dreadful dynamic at play. I could see all around me – and for the very first time – the pressure exerted upon us all by the very worshipful Evidence Based Medicine.

Now when I hear leading academics discussing their research, I hear a cold lifelessness in their data – probably quite necessary – but I also see this frigidity becoming inextricably fused with clinical practice. This language, this mindset and this academic posturing are transmitted subconsciously to clinicians – for where else are our role models to be found now, except in the form of these data-farmers?

Sometimes I wonder if we are now raising clinicians who cannot think for themselves, unless they have another wretched citation to support their point of view? The starting point is usually to flip open the laptop and search, rather than to simply wonder and reflect on experience.

‘Professors’ who measure their worth in terms of how many millions in funding they have attracted and who carry out ‘qualitative research’ solely to remind themselves what patients are really like – their evidence prowls…like an overinflated superego, encircling you and your patient, demanding attention…

Oh! The day of the clinical guru has long since passed, ’tis dead and buried – and some stamp on their graves with glee – for now we worship on our knees at the altar of ‘the evidence’: WiFi’d up and stoned on meta-analyses, we do a clever dance each day. But in reality healthcare remains deeply disconnected from it’s subject and i’m not convinced we are really in a better place than we ever were.


If you have been affected by any of the issues discussed in this blog – here’s a few suggestions:

  • A great starting point: Greenhalgh and Hurwitz 1999 Why study narrative? here.
  • The groundbreaking Causehealth Project, with a most refreshing summary from Stephen Mumford here.
  • The absurdity of it all summed up quite beautifully by Roger Kerry in video here from 45mins 30s.
  • Neil Maltby’s superb ‘Healthcare from a Human Perspective’ blog here will provide regular nourishment.
  • A few words from the visionary Dave Nicholls here. If you like that you’ll like this: Holmes et al 2006 The evidence-based discourse in health sciences: truth, power and fascism here.
  • Matt Low has engaged with the challenges of complexity, causation and clinical reasoning in his groundbreaking work here.
  • Where it all started – wise words indeed – echoing down the decades: Sackett et al 1996 Evidence based medicine: what it is and what it isn’t here.

Buffer photo credit: Bion Grillart