Letters

THERE seems to be small war beingwaged between the traditionalists inthe profession and those who espouseevidence-based practice. The article byMark Pinnington and the letter fromKeith and Nancy Banks in February’sjournal exposed these polarised views.

Evidence-based practice was neverintended to prevent us from utilisingour professions’ core skills. It is simplya reminder to clinicians to practiseclinical reasoning, ie to review currenttreatments and methods critically sothat resources are used effectively.

There is still ample justification forusing non-evidence-based treatmentsso long as therapists, patients andhealth purchasers are aware of theirlimitations and that continuous clinical

audit is carried out to evaluate theirefficacy.

The advocates of evidence-basedpractice argue that physiotherapistshave a tendency to confuse theory withevidence. For example, many of theclinical tests and treatments we employin everyday practice lack sensitivity andspecificity and yet we continue to usethem unquestioningly.

This is where gurus are able tomonopolise postgraduate education,taking snippets from the latest researchfindings, repackaging them with afancy name, and then selling themback to therapists.

In defence of the traditionalists,there are some aspects ofphysiotherapy that are very hard to

measure. There is considerablepressure on us all, as Voltaire once putit, ‘to entertain the patient as naturetakes its course’. Perhaps our greatestasset is our compassion and advicewhen patients most need it rather thanany specific treatments we provide.

We don’t have to throw out thefamily silver in order to practiseevidence-base physiotherapy. However,we do need to be aware of the fallibilityof our treatments and refrain fromfollowing dogma at the expense oftruth.

Richard Bartley MSc MCSP MISCPKanturk, Co CorkIreland

Do Not Follow Dogma at the Expense of Truth

Letters

I READ with interest Kevin and NancyBanks’ sentiments in the Februaryissue of Physiotherapy. I too am a'humble clinician' and am interested inthe way the profession is heading. I amenthusiastic about the issues relating to‘back pain revolutions’ and topicalissues in pain. Clinicians and activemedical practitioners, not in myopinion academic lecturers, largelydrive the issues and growth in interestin these areas.

The main reason for change inemphasis in intervention is perhaps notthe ‘great faceless 21st century guru –evidence-based practice’ but soundpractical clinical science andepidemiology. Throughout the westernworld studies indicate that patients atrisk of developing ‘chronic’ disablingpainful problems can be predicted –very early on.

Many people can be ‘disabled’ bymisinformation received by health careprofessionals and many have been --hence the need to change focus ofpractice, not abandon clinical skills.

A visit to any major painmanagement clinic is a humblingexperience … I ventured into pain

management clinics, read the literatureand read outside the narrow confinesof therapy literature and waschastened.

Listening to the stories of whatpatients have had ‘done to them’, and what intervention and therapyhave actually helped, revealed thatmany people for various reasons hadbeen ‘disabled’ by a pathology-basedtissue approach to restoration(surgeons, medical staff and therapistsincluded).

It is only by broadening the debateand perhaps enlarging ourunderstanding of the complexities ofpain-related issues that the professionwill be in a better position tocommunicate to patients and otherhealthcare professionals on an equallevel.

There are indeed many articles onchronic pain and coping strategies, etc,which is perhaps a sad reflection onreality -- ‘there is a lot of it about’…. Inan ideal ‘therapy world’ we would haveless chronic pain to deal with -- theclinical reality is the converse, ideallythe aim is to reverse the trend.

How to treat patients who are

commonly referred to departments ofrehabilitation will never be easy as thepathology and pain states are not wellunderstood (Haldeman, 1990). DavidButler covers an excellent overview ofthis issue and the need for change inphysiotherapy – see Topical Issues inPain 1998 which is highlyrecommended.

I too see physiotherapy as a practical,caring and educational profession,which offers as its unique perspective‘rehabilitation’ as its core skill.Pathokinesiology is one definition ofdisordered movement -- where fearavoidance is a dominant issuePhysiotherapists need to move awayfrom the tissues for answers to manyclinical pain problems and ‘doing’ lessmay be one way of achieving this.

The ‘guruism’ and brandedinterventions that often dominateclinical intervention are being replacedby an ‘alternative’ namely clinicalreasoning and pain science. There arelogical biological reasons for usingtouch and hands-on techniques formany of the reasons mentioned in theletter. I readily use touch, alternatingbetween procedural and intuitive

Chronicity, Models, Gurus - and clinical science

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Letters

approaches, which will never be subjectto randomised scrutiny but will alwaysbe a part of therapy. See Nathan(1999) for an excellent review of theseissues.

However, the way ‘techniques’, touchand practical skills work for some butnot for others is a complex issue and iswell covered by Simmonds (2000).

Physiotherapy is changing inresponse to the demands of a complexsociety. Clinicians are asking questionsregarding the efficacy of their work,which in turn generates researchquestions. Some clinicians are trying topull fundamental biological science,epidemiolgoy and practical skills

together into a much broadercomprehensive model to serve theprofession and patients better.

Models to explain poorly understoodlargely undiagnoseable pain states canbe useful rather than the entrencheddualism that presently dominates thefield. One approach was offered byGifford (1998) which I personally finduseful, since pain is defined by theIASP as a sensory and functionalexperience.

In some situations using a model toshift people’s thoughts and the waythey perceive pain may well be moreuseful than trying to find some often‘inconsequential’ physical anomaly.

Literature in physiotherapy is nowmirroring the change in thinkingregarding musculoskeletal pain,integrating pain physiology, movementand techniques in a biopsychosocialframework. One recent additionregarding this is The Sensitive NervousSystem (Butler, 2000). Have a look atthis text; you might be surprised at howacademic and practical clinicalintervention is working in tandem.

Ian Stevens BEd BSc MCSP Dunblane, Scotland

Banks, K and Banks, N (2001).‘Chronicity, models, gurus – and coreskills’ (letter) Physiotherapy, 87, 2, 112

Butler, D (1998). ‘Integrating painawareness into physiotherapy : Wiseaction for the future’, Topical Issues inPain, Physiotherapy Association Yearbook,pages 1- 23, CNS Press, Falmouth.

Butler, D (2000). The Sensitive NervousSystem, NOI publications, Australia.

Gifford, L S (1998). ‘Pain, the tissuesand the nervous system : A conceptualmodel’, Physiotherapy, 84, 1, 27-36.

Haldeman, S (1990). ‘Failure of thepathology model to predict back pain:Presidential address, North AmericanSpine Society’, Spine, 15, 718-724.

Nathan, B (1999). Touch and Emotionin Manual Therapy, ChurchillLivingstone, Edinburgh.

Pinnington, M A (2001). ‘Why are wefinding it so hard to change ourapproach to low back pain?’Physiotherapy, 87, 2, 58-59.

Simmonds, M (2000). ‘Pain and theplacebo in physiotherapy: A benevolentlie?’ Physiotherapy, 86, 12, 631-637.

Stanley, I, Miller, J, Pinnington, M A,Rose, G and Rose, M (2001). 'Uptake ofprompt access physiotherapy for newepisodes of back pain presenting inprimary care', Physiotherapy, 87, 2, 60-67.

References to the letters from Mr Bartley, Mr Stevens and Mr Rouse

TRYING hard not to be a traditionalist(Pinnington, 2001) I attempted to linkthe three elements covering low backpain in the February 2001 journal –which I found extremely difficult to do.However it has led me to make thefollowing points:

Pinnington, in his editorial, accusesus of being slow to put the principles oflow back pain management intopractice and using approaches that arenot evidence-based; yet in the followingarticle (Stanley et al, 2001) he seems tobe advocating, in some way, those sameapproaches.

In addition, Banks and Banks (2001)seem to have written the perfectresponse to the first article where theyargue that evidence-based practice isthe 21st century 'guru' and thusignores the core skills of

physiotherapists. Usually we have towait for this type of comment until thefollowing month -- it reads as theperfect antidote to Pinnington'sperspective.

The publication of these threeelements in one journal has caused meto reflect on the situation -- perhaps Iam an innovator (Pinnington, 2001)and though not coming to anyconclusions I feel that the journalwould benefit from more situationswhere the argument is presented as amore rounded one. I know, in thissituation, it has happened by chance.Possibly in the future it may occurdeliberately.

S J Rouse MSc BEd MCSP DipTPLeeds

Michele Harms, scientific and clinicaleditor of Physiotherapy, replies:

The three elements in the FebruaryJournal stimulate healthy debate. As you point out, these provide variedperspectives on the management ofand approach to back pain. In thefuture, I hope that we will be able toprovide this diversity of views on othersubjects, to give readers of Physiotherapyaccess to contrasting opinions so thatthey may make up their own mindsabout the quality and soundness of theevidence provided. To develop Banksand Banks’ metaphor: they can decidewhether their ‘guru’ be the humbleclinician or evidence based on soundresearch.

As we move away from prescriptivemedicine, decisions that we makeabout treatment approaches will notalways be comfortable. However, Ibelieve that controversy heralds theadvance of a thinking profession.

A Perfect Antidote

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