The case against Evidence Based Practice

Over the last decade, the physical therapy profession has been consumed with evidence based practice. This is likely derived from an inferiority complex when comparing themselves to physicians and chiropractors. Those who determine the direction of physical therapy in the U.S. decided that better letters after a therapist’s name and a focus limited to what they felt had adequate research to ‘back it up’ would give them more legitimacy. That would make them more like doctors.

But there is a great difference between reading and digesting research with the intent to try incorporating it into a practice and throwing away useful tools because they haven’t been researched ad nauseum. The former is a logical approach to marry science and art. The latter is an arrogant and dismissive means to minimize the efficacy of the profession. A skillful and experienced therapist can use new research to prune from his repertoire those things that research indicates are marginal or feckless. Young therapists possess neither the palpatory skills nor the clinical judgement to do this. Schools now close their minds by telling them ‘this is the only way evaluate or treat this problem, and you don’t need to learn other approaches’. Feeding their egos and closing their minds greatly damages the profession.

But research is good, right? Research in the field of physical therapy(or chiropractic for that matter) is rife with flaws. For starters, it generally tries to study that which is subjective: pain. Researching back pain is quite different from researching something with more objective measures like a hormone or white blood cell count in the blood stream. Determining the group to study is a nightmare. Let’s say you want to study a treatment approach to low back pain. You could limit your study participants to only people who had a disc bulge or herniation confirmed by MRI with some frequency or chronic duration of pain episodes. But we already have research showing that a majority of people with that type of MRI result don’t have back pain. We also know that emotional states will increase back pain. Organs produce back pain. Sacroliliac dysfunction will relate to back pain. Various muscle produce back pain. If you can’t restrict your study to participants with the same cause of symptoms(disease or disorder) then what use is the study?

And where is the funding for this brave new world or research? Are pharmaceutical companies begging to get answers for what exercise or manual therapy can do? How about the NIH? Let’s face it, research in this field isn’t just hard to do. It’s not funded like the big boys either.

And last but certainly not least: What makes the evidence lovers think that condensing treatment down to one treatment approach is of use? A body is a complex system where symptoms can arise only after its ability to compensate for various problems is exhausted. I don’t look for one magic key to fit into one lock that will change the patient’s life. I use multiple approaches to identify and treat a host of different things to reach the goal. I might see a ‘back patient’ and move from the foot to the sacroiliac joint then focus on several muscles like a hip flexor(which attaches on the lumbar spine) and a leg or calf muscle. I might do all this and finish with fascial manipulation in that region or move up to treat the apposing rib cage and shoulder. I might also treat organ adhesion/scarring along with the function and drainage of the pelvic floor. Rarely ever would my treatment be limited to a regional approach like some one trick pony in a research article. Just how does someone study the efficacy of that approach?

And where has this new gold standard taken the profession of physical therapy in the U.S.? Down the road to reductionism. To a place where skilled older therapists who have been treating patients for multiple decades sit over lunch talking about how difficult they find it to hire a young therapist capable of learning. Words like ‘brainwashed’ and ‘arrogant’ generally pop up in such conversations as they lament where the profession is heading. Behold the new era where we try to wow patients with a degree and hubris instead of getting them better.