Does a physiotherapist with a PhD automatically make the best clinician? Should patients with the highest standards and discernment be looking to get treatment from a PhD physiotherapist whenever possible? I've got an opinion on that. Let's go back in time a bit:
In the Health section of my local newspaper years ago, there was a story on low back pain called "Ask the experts". It featured a well-regarded, highly decorated PhD physiotherapist from the local university, who summarized the research on low back pain something like this: "There is no research to suggest that any one type of exercise is more effective at treating back pain than another." And that was it. No further explanation on the topic. No suggestion that a reader might want to consult one of his colleagues in the clinic and get some in-person advice. In fact shortly afterwards I overhead in the clinic one day a PhD candidate physio give a version of this same advice to a patient. A week later, that same patient came to see me instead.
Our PhD colleagues at the university level are true experts in academia. That does not necessarily mean that they make the best clinicians. Think about that statement for a moment. They know the research better than anyone. But knowing the research alone is not enough. And within that paradox lies the Art of Physiotherapy.
Trust the science
"Trust the science" is a bit of a loaded statement, here in Canada, after going through the COVID era. The intent of that statement is to reassure people that science is trustworthy. And yet people in the know bristle a bit at the finality of that statement. Science is ever evolving, and what we think we know today is updated and changed tomorrow. Here's an example in the history of back pain:
During the enlightenment, low back pain was lumped in with a category of diseases called rheumatism (1). And the literature of the time blamed rheumatism in large part on exposure to cold (2). In essence, the science of the time suggested that some forms of back pain can be attributed to cold exposure.
It wasn't until the early 1800s that physicians started to suggest that back pain might have it's origin in the bones and nerves of the spine itself, and that trauma may have a role (1). As we moved into the 1900s, the idea that cold weather caused rheumatism and therefore back pain became a cute relic from the pre-modern era.
And yet! The past 2 decades have seen the adoption of new models of pain that unearth the role of cold sensitivity in pain perception (3). There is evidence that chronic back pain leads to nociplastic changes that can hypersensitize a person to cold exposure (4). The enlightenment physicians were on to something. Perhaps it wasn't exposure to cold that caused the back pain, but when their patients told them that the cold weather made it worse, we now know why.
The most current evidence on LBP diagnosis
What do you tell your back pain patients when they ask you "what's the diagnosis?" Here's what a May 2023 systematic review of the literature advises us: "There are informative diagnostic tests for the disc, sacroiliac joint, and facet joint (only one test). This evidence suggests a diagnosis may be possible for some patients with low back pain... potentially guiding targeted and specific treatment approaches." (5) You read that right. "MAY be possible". "POTENTIALLY guiding treatment." That's straight out of the esteemed journal The Lancet.
Does that statement inspire confidence? Would any patient be willing to seek your advice if that's how you advertised your practice? Feel free to give it a try! You might end up like the Maytag repairman.
Exclusively incorporating this bit of evidence into your practice does not lead to the best outcomes. We do better than that.
Clinical Practice Guidelines
Here's a controversial statement: Clinical practice guidelines (CPGs) are out of date the moment they are published. Stop and think about that for a moment. We are taught that CPGs are the best-evidence; that we should refer to them as a standard of practice. Personally, I agree that this is a good starting point. But knowing how CPGs are put together is important:
The clinical practice guidelines on neck pain published by JOSPT in 2017 are a good example (6). Their literature review went as far back as 2007. And we know that any published research comes from studies that may have been conceptualized and commenced years earlier. Therefore the most recent neck pain guidelines that we have from JOSPT come from as far back as 20 years ago.
This is not to discourage the use of the evidence. This is merely to put it in it's place. The science must be the foundation - in that sense it is behind our practice - it's what we base our approach on. But by nature, it is often also lagging behind what we already know to be true in our clinical experience. I like the double entendre in that: The science is always behind the art.
Most of the research on physiotherapy is conceived and studied based on procedures that are already in practice in the clinic. Clinicians experiment, and claim that an assessment or treatment technique has clinical validity, and then the academics try to prove it. So how do we ensure that when clinical practice guidelines are published, we are already following most, if not all of the recommendations? Because an excellent practice should have that as its goal.
"The practice of medicine is an art"
It was the venerable William Oser that said this. Many have said as much since then in other ways. In fact the Physiotherapy Guild is dedicated to the promotion of both the Art and Science of our profession.
In my practice, I am comfortable living in that tension that comes between relying on the research and providing answers to the patient; answers that I might believe to be true, but that are not backed up (yet) by vigorous research. To much reliance on one or the other is a practice out of balance.
I invite your thoughts and comments on this issue.
Jeff Begg, PT
1 Allan E, Waddell G. An historical perspective on low back pain and disability, Acta Orthopaedica Scandinavica, (1989) 60:sup234, 1-23
2 Heberden W. Commentaries on the history and cure of diseases. Payne & Foss, London. 1816
3 Thermoregulation: From Basic Neuroscience to Clinical Neurology Part I
Félix Viana, in Handbook of Clinical Neurology, 2018
4 Hübscher M, Moloney N, Rebbeck T, Traeger A, Refshauge K. Contributions of mood, pain catastrophizing, and cold hyperalgesia in acute and chronic low back pain: a comparison with pain-free controls. Clin J Pain 2014 Oct 30(10):886-93
5 Han C, Hancock M, Sharma S, Harris I, Cohen S, Magnusen J, Maher C, Traeger A. Low back pain of disc, sacroiliac joint, or facet joint origin: a diagnostic accuracy systematic review. The Lancet. Vol 59, May 2023.
6 Neck Pain: Revision 2017. Blanpied P, Gross A, Elliott J, Devaney L, Clewley D, Walton D, Sparks C, Robertson E. JOSPT 2017 47:7, A1-A83