Recently, a blog post I wrote about limitations of spinal manipulation got me fired!
Somehow that doesn’t surprise me, maybe that’s just what happens when you rattle some dinosaur cages. A dinosaur in physiotherapy is someone who is stuck in the past, and refuses to update his/her views with new evidence unless it feeds their confirmation bias (1). It’s obviously not a technical term, but a valid description that I am by no means the first one to blog about (2). It’s also not a blanket description of everyone that graduated before me. It’s not the age that defines the dinosaur, but rather the attitude. There’s plenty of physios with many years of experience that still remain open to new ideas and evolve their practice to reflect these ideas.
Dinosaurs and their followers are very prevalent today, even among the young folk who work with and are influenced by the older ones. It’s only in recent years that evidence based physiotherapy is flourishing, facilitated by the explosion of research (3) coupled with social media that allows the open discussion, criticism, and dissemination of information by physiotherapists (4).
And, naturally, the dinosaurs are pissed. Not only has almost every therapy they have been providing failed the test, but the whole paradigm of why these treatments should work has failed. Dinosaurs are too deeply committed to these outdated ways of thinking to objectively evaluate the science, too married to old ideas to divorce them. To them, decades of consistent research can be brushed off with “you can feel it working”, or “It’s been working for years!”, or even the abysmally short-sighted “I have a waiting list so I must be doing something right”. They are in an endless loop of using temporary analgesic effects to justify unnecessary or even harmful treatments, confusing immediate patient satisfaction with good clinical outcomes and consciously forcing patients in dependency instead of promoting self-efficacy.
So when I challenged the dinosaur viewpoint by pointing out that there are important limitations to spinal manipulation, I got fired.
Icelandic physiotherapy is undergoing a silent crisis, and in my opinion dinosaurs are causing it. The average out-patient physio in Iceland sees ~5,5 patients per day (5), which is less than a full time job. Some of the more popular ones see 18+ patients per day, which means that at the lower end are physios who hardly see any patients at all.
Seeing 18 individual patients per day can’t be considered ethical practice. That means working 9 hours straight, without a break, every day. Making decisions and staying focused becomes difficult (6). It gets more and more tempting to just do the easiest thing, and that often includes providing passive analgesic therapies. Using active treatments and engaging the patients in a therapeutic union takes presence of mind and concentration. I would sure not like being patient number 18.
Discussing treatment options and prognoses – real prognoses, not a unicorn story – may end up with a patient deciding not to attempt an intervention. And that’s ok, people have a right to accept or decline any medical treatment plan. It is our job as physiotherapists to provide patients with the best possible information regarding their condition and work with them to tailor a treatment plan. This may include various therapies if indicated and the patient chooses to use them after discussing it with the physio. But sometimes, this includes one of the hardest decisions a physio makes: recommending no intervention at all.
Other times this may include something unpopular, such as recommending that a patient skips a competition or a planned trip. In that situation, it’s our job to provide the patient with information regarding possible risks associated with participation, but the patient usually makes the final decisions, after all it’s their risk. If the therapist is greed-driven, working from a business model of more sessions per patient = better, these are surely worthless strategies. In that case, it’s much better to tell the patient „we’ll do everything in our power to make that trip!“ and proceed to throw every therapy under the sun at the patient and hope for the best.
Dinosaurs have indeed become good at milking as many treatment sessions as possible out of every single patient that walks through their door. They take their money by spending countless sessions fixing imaginary blocked sacroiliac joints, softening up tight muscles, and telling stories about remarkable single-session quick fixes.
The same udder-squeezing skill-set results in increasing numbers of patients who realize they spent considerable time and money for little benefit. This in turn creates people who are skeptical about physiotherapy, and will just stop booking sessions. It’s a vicious cycle of over-treating causing decreasing numbers of sessions, resulting in increased over-treating.
Evidence based physiotherapy is – compared to the bloated dinosaur therapy – streamlined, resource-efficient and requires much fewer treatment sessions on average. It’s a scalpel next to a chainsaw. It’s a breath of fresh air next to a garbage dump. Even the popular dinosaurs can smell the change coming, and they are stressed enough over it to fire people like me for making the patient better informed.
Even patients that receive a fake therapy, literally a machine that is turned off, will still improve with treatments (7). This means that every physio will get apparently decent outcomes by simply being equal to the passage of time and a machined turned off. The goal is to provide the patient with information about their condition and the efficacy of possible treatments. Every intervention attempted should have a good chance of performing better than time, and to that end it’s so important to use the research evidence to weed out the useless therapies and set reasonable treatment goals. If no treatment is indicated – the patient will receive information regarding his condition, but no voodoo tricks.
The trend is to increasingly emphasize evidence-based physiotherapy in physiotherapy education. It’s also increasingly emphasized that the knowledge gap between science and the public should be bridged by communicating findings to the public. I got fired for just that, discussing information and evidence – evidence the dinosaurs obviously want to sweep under the rug so they can remain complacent and their clients blissfully ignorant. I believe more physios need to openly support evidence-based physiotherapy and speak up against these outdated methods and together we just might be the meteor that saves physiotherapy.
Haraldur Sig 
That’s absolutely brilliant. Respect your guts coming out with this. THIS will hopefully spark some gap-bridging and knowledge based debate.
Thank you for this. Hopefully it’ll spark some discussions in the community.
And for your information: The Norwegian Physiotherapist Association just linked your blogg out on Facebook 🙂
Dude, no offense as physical therapist myself. Evidence based medicine, definately in physical therapie is the worst what physiotherapie has overcome. No patient is the same and that is the problem with it. Making a personal treatment plan based on non personal evidence based physiotherapie treatments is impossible and outright wrong. Getting ur ass fired for following a religion, which is nothing more as a trend itself and failing to see it are for me reasons enough. In the end it will cost your chef patients and money. Reasons enough for getting you fired.
Be a good service (product), don’t wish and believe to be it.
This is a common criticism of evidence-based practice, which in my view is unfounded.
You assume that I pull my treatment plans out of some rct or another and throw it at the patient without regard to his or her personal circumstances. This is of course far from the truth.
Using the evidence to a high degree mostly means that I can streamline my practice; can often make simpler recommendations, can skip wasting time on methods not shown to be effective for some patient groups or others, and provide higher quality information to my patients.
The process is the same for a dinosaur and an evidence-based practictioner in that we use information (of different sources), and individualize within that paradigm for each patient as needed.
It is less compatible with religion than dinosaur practicing, because instead of believing in something (like a method or a guru) I look at the facts instead.
Thank you for your comment and your well-meaning advice.
Well said, sir. I hope you land on your feet – in a more suitable environment – soon. Sadly, in the USA, the frequency model you write of (one patient every 30 minutes) is regularly exceeded in outpatient clinics.
It seems that your practice patterns and values differed from the dinosaur’s long before you wrote a blog posting. Was the posting just „the last straw“ or did it open up the dinosaur’s eyes to how incompatible your views were with their own antiquated view of therapy?
Prior to this there were some tensions already. I was (and am) outspoken, but I like to think I’m not impolite or insulting although other people should judge that.
No one ever criticized my methods or the results my clients were achieving, and there were no patient complaints that I know of. I was criticized for how few sessions I booked per patient on average, but I don’t see that as a negative as long as the results are there. In the end, I was just a little too public with my opinions.
Thank you for your comments. In Iceland there is no hard „30 minute“ limit, but when I graduated a while ago it was assumed that each patient appointment required about 45 minutes of time (including admin). There was a 30 minute limit set by the national health insurance until a couple of years back. These days, you’re just expected to use as much time as required.
So the frequency model is even out-dated here. Personally, I like to take a few minutes to discuss things with my clients and tend to use an entire 30 minutes or more for most people. I’m sure I could use a lot less, but I don’t think it would feel as comfortable for my clients.
What a fantastic blog Haraldur Sig. Well done for the having the courage to do what it best for your patients. Evidence based practice!
Thank you for your kind words.
I am of an older generation than you. I’m wondering if you’ve heard of science-based practice? You might like some of my writing on Somasimple.com or my website, barrettdorko.com
Thanks for the tip, always up for a good read. I’m quite familiar with Somasimple, and used to be a regular visitor on the forums there.
Good job sir, standing up for well-being of the public and the profession at large. You are a treasure to the profession. You have our respect and support Haraldur.
can anyone provide a quick example of a dinaosaur therapy and an evidence based one please? (for the same condition if possible)
One example would be a patient with low back pain presents at a clinic. Dinophysio examines patient, palpates range of motion between individual vertebrae, discovers a left-on-right sij blockade, performs a manipulation to correct the blockade – performs the motion palpation again to find the correction is good. Patient feels better and walks out thinking the physio fixed his „stuck“ sij.
Same patient reports to an evidence based physio, who knows that motion palpation is not a valid examination technique, and that sij motion testing requires sophisticated machinery. So proceeds to do f.x. provocative testing with known validity and reliability scores to find a best guess of source of pain. Explains to patient, offers treatment options and informs about the efficacy of them. Then some kind of treatment plan is usually made with exercise, a load management strategy, and/or a spinal manipulation, based on factors associated with the pain.
Some of this (as much as possible) will be based on evidence, but usually there is also a big part which is a guess based on what is known. So not every evidence-based physio will prescribe the same line of treatment etc (we’re not robots, although some might feel like we are).
The real difference is, that for dinophysio to perform the treatment he does (and in these cases, usually the dino performs similar treatments with insignificant differences on most or all of his patients) he needs to either be unaware or simply ignore a large body of evidence that says that what he’s doing is non-sensical.
The example ignores a lot of other aspects, like the influence of social status, fear of pain and other factors that will influence how the session goes.
Hope this helps.
Reblogged this on Fisiosofía.
A Physiotherapist blogs about dinosaurs, a person or thing that is outdated or has become obsolete because of failure to adapt to changing circumstances. BUT courses advertised for MSK Physios are technique based, focus on biomedicine & quasi evidence based treatment often no better than placebo. I refer to acupuncture, dry needling, kinesio taping, myofacial release, kinesiology, electrotherapy, joint mobilization and more. If we remove all these debatable treatments from MSK clinical practice then we are left with a clinician giving simple early stage advice on healing and exercise/physical activity. MSK is a dinosaur field populated with obselete nonsense treatment. By contrast there is plenty of scope for work in functional rehabilitation within neuro, amputation, spinal injury, paediatrics, cancer care, elder care, health promotion and lots more.
That was a great blog post. Very interesting what you consider a dinosaur. Maybe I am considered a dinosaur. I try and stay somewhat current with the literature but it does not always change my practice. Remember that evidence is only 1/3 of the evidence based practice. The other 2/3 are the patient and clinical expertise.
In my practice, all I use are my hands (manual therapy), IMS (dry needing), kinesio taping and exercise. The only thing that I use has good evidence is exercise.
Old research is not bad research, just as new research is not always good research.
What if new research comes out to support ‘motion palpation’. Would you suddenly change your practice? Or would you become a dinosaur yourself?
Great question. A thought experiment I like to do is to consider what evidence I would consider adequate to change some of my physiotherapy beliefs. Here’s my thoughts on what would be sufficient in my mind for me to adopt motion palpation techniques again.
In my mind, a lack of support is not proof of in-effectiveness. However when a method like motion palpation (which I used for years) proves invalid I had little difficulties stopping that.
If someone comes up with a method that proves valid and useful, I’d like to see it studied compared to imaging studies of mobility. I’d also like to see the effects of a manipulation or treatment based on it to be studied using the same imaging techniques. Some objective physical measures on the manipulation, such as range of motion, strength, muscle activation changes etc need to follow and shown to be different to those receiving the manipulation without the imaging findings. If that is shown, I’d consider adopting the techniques if the learning curve is reasonable.
I don’t like to heavily buy-in to methods or theories in physiotherapy, because I feel it would make me not give them up to new evidence. So the core principle I hold on to, is to follow the evidence as best I can , provide the patient with the best information I can, and support their decision for care.
Perhaps I’ll become a dinosaur some day. I hope to surround myself with good critical thinkers who will let me know when it happens.
That being said, I think the future for spinal manipulations and motion palpation will be using ultrasound imaging instead of this palpation deal. I see potential for ultrasound attachments as a tool to guide and target manipulations much better than palpations can.
I do think that your blog post is absolutely brilliant. It talks about many realities that are presented in many countries and sadly it is a normal thing in South American countries and Spain (although, hopefully it will change soon). Something that we forget many times is that patients are not numbers and manners and ethics should always be, at least, as important as the treatment itself. Treating for 20 minutes and in a rush makes the patient (person) feel a number and that is going backwards in our profession. Something we all should remember, we are physios to help people (money comes second). Many thanks for your great article.
Thank you for your kind words.
Great point, I’m hopelessly against money as an influence on my practice. I make an effort to make the patients really feel that I want to help them, and hold their best interests at heart. The money is something that needs to come somehow somewhere, but I try not to think about that too much.
I have no difficulties seeing why this attitude is perhaps not very popular in all business models 🙂
I too go through this every day. Most physical therapists I know are still treatment focused and not outcome focused, constantly looking for assymetries and joint restrictions in joints that move a few mm, or look for delayed muscle activation that takes place in micro seconds.
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Thanks a lot for these words. You can see that these dinosaurs are still alive and love to talk religios bullshit further. Your analytic pathway is very interesseting and kind to my thinking. In Germany we have these big problem too. I think there are just the most living dinosaures and it feels like to tilt against windmills.
But keep your head up, I think the EBP is a process like the darwinismus and take his owen way. In that way we need heads like yours to break trought old habits. Anyway a bit anger by a dinsosaur is the first step for rethinking. I did these process too and get a new view for patient centered working.
Geers