Wednesday, 28 October 2015

Forget models, mantras and gurus ... Listen to the patient

The current debate in Physiotherapy about the use and misuse of evidence based medicine (EBM) was well and truly polarised by Roger Kerry's recent Evidence-Based Physiotherapy: A Crisis in Movement.

In a brilliant no holds barred polemic, the author called made a plea for sanity in a World gone mad. It got me to thinking. I've long been an advocate of big picture thinking, and puzzled for many an hour and longer about why we think the way we do. Why for instance, physiotherapists got fixated with the vertebral artery, back in the day when spinal manipulation was all the rage. It slowly became apparent that there was more to cervical vascularity than just the vertebral arteries. Hence the development of a system based approach to the issue which focused on movement (not JUST manipulation), all of the vascular system (not JUST the vertebral artery) and all of the potential pathologies (not JUST dissection).

The result was a risk assessment framework which offers sound guidance and direction for those offering any movement based interventions (including assessment) for patients with head and neck pain. The IFOMPT document is not a guideline, rather a framework for THINKING, for clinical reasoning, and directs clinicians to make decisions based on the big picture. It exhorts clinicians to familiarise themselves with cranial nerve testing, surprisingly, (and perhaps alarmingly) not part of the skill set of many PT's, and to consider blood pressure as an additional risk assessment tool. None of this was rocket science BUT, it was perhaps an example of restricted thinking, dominated by the 'experts' of the time.

The new 'experts' of our time are the social media commentators, the 'institutes' the 'organisations' who shape our opinion with their interpretation of EBM. Many seem to shout loudly (and with significant bias) from the roof tops about what we should or shouldn't do. It is a fascinating dynamic, which I have observed from both within and afar. When internationally respected pain expert Mick Thacker wrote a guest editorial recently for Pain and Rehabilitation - the Journal of Physiotherapy Pain Association, he upset the apple cart. He challenged the use of 'mantras' and singular thinking with another brilliantly written piece entitled 'is pain in the brain?'  His commententary, that he was surprised that such views about pain were "…so widely accepted by physiotherapists considering our backgrounds", caused outrage in some quarters and he was was vilified on social media by disciples of the pain/biopsychosocial model. They argued their case with such tactical vigour, you would have to conclude they could not be wrong …. unless of course, you were thinking.

It is perhaps the absolute certainty of some, that I find most fascinating and perhaps a little dangerous.

It is time, as my colleague so rightly said, that we all begin to think for ourselves.

Image via

There's no doubt that the biopsychosocial model has much to offer and only a fool would deny its role and value. But should you throw yourself at its alter? The biomedical model has many limitations, that are well recognised.

But when a patient presents with a worsening scenario, it is worth remembering that not everything is a 'flare up' and just as 'hurt does not always equal harm' ... SORRY but, sometimes it does!

Similarly, whilst modern science suggests most patients with LBP for instance don't require scans or X rays … some do.

It remains our job to be able to recognise those cases and manage the others with whatever skills we have left at our disposal. Otherwise, a sheep like adherence to one particular school of thought may prove to be our undoing. We need to know examination skills, we need to know pathologies … we need to know when scans or triage are appropriate, we need to know the limitations of our own thinking, all these things matter.

I decided to illustrate my point with a cute story ... which nicely illustrates the shortcomings of both 'models' and how we truly have to listen to our patients and put aside our preconceptions.

Mr Xrayspecs (a 52 year old builder and hobby cyclist) walked into my clinic recently, referred from another Physiotherapy colleague. He presented with a description of chronic lower back pain and non specific left leg pain.

I introduced myself and asked him why he'd come to see me.

"Well, I have this pain you see, and I think it's getting worse, so my physio sent me to see you … seems to think you might be able to help" he said, somewhat doubtfully.

"Tell more about it " I asked.

"Well it all started 34 years ago". "34 years", I mirrored and sat back in the chair ready for the long haul.

"They've tried everything" he went on. First, when my leg started aching (aged 18), they said I had a trapped nerve 'sciatica' they called it. They said I'd got an asymmetry. They gave me lots of treatment, you know manipulations and stuff but nothing worked. Then I went to the osteopath and he put all my joints back in … but that didn't work either."

It was a familiar story ... one I've heard (probably like you) many times before.

He went on "I just tried to ignore it and carry on riding my bike, but the pain came on every time and my leg felt weak."

Oh, so you felt it whilst you were cycling did you?" I interjected. "YES", he reiterated with some agitation. "Tell me more", I asked, ... "They said I must be trapping a nerve or something, probably because I was bending forward, on the bike". "Oh" I said, thoughtfully. "Then they sent me for a scan, but nothing showed up". 

He continued, "I was getting really fed up I can tell you, and about 3 years had gone by". "OK, I can understand that" I said compassionately. "Then what happened" I asked. "Well, thats when they said it might all be in my head" he said (his words). "They sent me to a pain clinic, gave me some injections and told me I should self manage it, but I knew something was wrong". "Oh" I said, brilliantly … pausing for dramatic effect.

"What did YOU think was wrong" I asked. "Well I didn't know what exactly ... but I knew my leg wasn't right, it felt weird, weak, strange, but when I started to say that, I think they thought I was a bit mad, so I backed off a bit". "Oh" I said again, somewhat repetitively, but he carried on regardless.

"I've been to every specialist you can name, orthopaedics, sport, pain, physios, osteopaths, chiropractors, masseurs, you name it, I've been there". "And" I said, probing hopefully. "Well its just getting worse and now I've got back ache too" he continued. "They sent me for more scans recently and I've got wear and tear and disc degeneration now ... and they said that must have been the problem all along".

"So now I'm labelled with chronic pain and I'm having CBT and all that psychological pain education stuff". "Oh", I said hopefully. "Yeah but that's a waste of time, just like the rest of it was … pacing whats that gonna do? Mindfulness? I'm a bloody builder … I'm getting worse, not better and NOBODY LISTENS", he said, pausing for effect.

"What do you mean" I said. "NOBODY LISTENS" he said again, somewhat menacingly.

Image via -

I leaned forward, listening intently with wide eyes. "Look when it all began, it always came on when I was exercising, and it still does, like when I ride my bike, or push a wheelbarrow on site or go up the steps to the roof … I might have back ache now but I didn't before and my leg still feels like it's got no blood flowing into it. To be fair I've been saying that for 34 years but everyone glazes over … Its like they only want to fit you into their bag, their particular pet theory".

At that point I laughed out loud. "It's not funny" he said. "No, no" I apologised, "I'm not laughing at YOU, I'm laughing at me ... US!" I stuttered.

"What do you mean" he demanded. 'Well" I began, " I think my colleague may have sent you to see me because he thinks I may have a pet theory too" … It went quiet … I took up the cudgels.

"When you said that your leg felt like it had no blood going to it, did anybody test for that." I asked. "No" he said, "they just kept talking about nerves or discs initially, then chronic pain and CBT and how 'pain is in the brain' and stuff, like I explained." he said.

I asked a few more probing questions about the nature of his pain and asked him to lay on the couch.

I took his lower limb pulses - Normal.
I took his brachial blood pressure - Normal.
I took his ankle blood pressures - Normal.

I asked if he was still riding his bicycle and if his pain still came on with cycling. "Yes" he said, "as regular as clockwork … as soon as I get to 145 bpm on the heart rate monitor." "Oh" I said. "Can we ask you to exercise to that level I asked'?

"You can bloody well ask me to do what you like if we can get to the bottom of this bugger" he said cracking a smile for the first time. I explained that we may find nothing at all, and asked him again if wished to continue with a simple exercise test. He was already climbing eagerly onto the exercise bike and adjusting his pulse monitor belt.

The exercise test quickly reproduced his leg pain as predicted, as soon as he reached around the 145 bpm mark. I pushed him a little further… 165 bpm "Yes", he said with some satisfaction. "Now my leg feels funny, weak, like theres no blood going to it".

He jumped off the bike and we lay him on the couch … we replaced the left and right BP monitors onto the ankles and inflated them, they ran simultaneously.

At minute 1 (post exercise) the systolic brachial BP was 185 mmhg

At minute 1 the right ankle systolic BP was 160 mmhg. The left recorded nothing (I waited … I'd seen this before) ... the BP can be lower than the machine can record.

At minute 2 the systolic brachial was 180

At minute 2 the RIGHT ankle BP = 155

At minute 2 the LEFT ankle BP = 70 mmhg 

Post exercise ankle brachial pressure index (ABPI) was calculated as 70/180 = 0.39

The published cut off point for post exercise ABPI is currently 0.6 (Peach et al, 2012)

I'd turned the BP monitors away from his gaze … He was anxious to know the result.

I explained that he would no longer need to continue with the mindfulness and CBT.

He was referred to the vascular surgeon with a full outline of the consultation and test results.

4 weeks later (after the tests had been repeated the vascular clinic) magnetic resonance imaging of the arteries revealed a significant flow reduction to the left lower limb in the region of the external iliac artery.

The patient underwent a 5 hour vascular surgery (longer than expected due to the complex intra-operative findings) involving endarterectomy and shortening of a 'significantly tortuous artery'.

He made a full recovery and 6 months post surgery reports NO LEG PAIN under any conditions, including exercise. He still gets intermittent low back pain, which he considers to be "normal".

His post exercise ABPI measures have returned to within normal limits (> 0.6)

He has returned to full function work/cycling/running/skiing with NO LEG SYMPTOMS.

For various reasons linked to clinical reasoning and therapist/physician beliefs ... it took 34 years to get to the bottom of this case.

For an analysis of quite how that could be ... try a stab at the 5 Whys of ROOT CAUSE ANALYSIS 

What do we all have to learn from this case.

1. Listen to the patient

2. There are limitations of BIOMEDICAL reasoning

3. There are limitations of BIOPSYCHOSOCIAL reasoning

4. NEVER have blind faith for 1 paradigm

5. Know your pathology


7. N=1 (it REALLY does)

8. It's OK to be discombobulated ... Just say "Oh"

 ... and just for the record, there is NEVER absolute certainty.

Image via Steven Shorrock

Author: Alan J Taylor is a writer and critic who thinks about stuff and works as a Physiotherapist and University Assistant Professor ... The views contained in this blog are his own and are not linked to any organisation or institution. Like Bukowski, he 'writes to stay sane'.

You'll find him mostly on Twitter
... that is until, he finally deletes his account, or is 'evidence based blogged' to oblivion. 

Monday, 23 February 2015

Forget gurus, the cult of the evidence-based blogger has taken over ... 'Biased BLOG Bingo'

WARNING! This blog may contain traces of humour ... 

If you suffer a sense of humour deficit ... DO NOT READ ON!

Some time ago now, I had the pleasure of reading an excellent article by Will Self called ‘The awful cult of the talentless hipster has taken over’ … 

Whilst I didn’t necessarily agree with his diatribe entirely, I lapped up the trademark dour humour, empathised with his view and thoroughly enjoyed the read. Then in a bizarre moment of thought association, my mind turned to my own area of interest, Health Sciences and evidence based practice (Physiotherapy in particular) … though this undoubtedly pertains to medicine and all other areas of health care ... I began to ponder ‘the cult of the evidenced based blogger’, which now appears to pervade the zeitgeist of our increasingly confused World

Don’t get me wrong, our World is important (to us … and the people we care for, hopefully) as is the evidence. I like and respect (most) bloggers (cos’ they’re out there), I blog myself … But sometimes I begin to wonder about the whole process, or perhaps question the motives of the bloggers (myself included).

Bloggers and Twitterati, these days are ubiquitous; everyone seems to be having a go and some appear to be very authoritative. Yet blogging is a strange and precarious pastime/hobby/profession, which is both time and thought consuming. So, unless they are getting paid for it (some are … Will Self falls into that category), one would have to debate what motivates the ardent blogger. Shouldn’t they have just gone out for a run or cycle ride or something? 

What would actually drive someone to spend valuable time writing and airing their thoughts on any topic? What drives them to risk an avalanche of comment/critique if their particular diatribe hits the wrong button, or perhaps, a rising tide of gushing agreement from the ‘Bloggioso’ or the ‘Twitterati’ for their latest fashionable and populist masterpiece?

Some blogs are really helpful (or are they?) because they interpret and decipher some of those peer reviewed papers (which to be fair, may be a bit complex/wordy). So blogs may appear really helpful for those busy clinicians who only get limited time for reading/analysing the latest news on a topic.  

One clear attraction of blogging (for bloggers), unlike the restricted writing of peer review for instance, which requires writers to declare conflicts of interest ... is that you can say what you like … and it is clear that some bloggers ‘like what they say’.

But … is what they/we say, prone to BIAS or subject to ‘conflicts of interest’ as a result? 

To help my own decision making, I decided to gather a concoction of my own observations on some of the blog sites that may be influencing how we think and view evidence. Some bloggers may see parts themselves or their writing in one or all of the types (I did). That's not really the intention. Rather, it is for readers to see how a topic may, or may not, be spun.

I'll leave you to decide what you think ... Perhaps after a lighthearted game of 'biased BLOG bingo'.

I wrote about this in my last blog, so if you haven't already, take some time to consider the definition of confirmation bias ... 'the tendency for people to favour information that confirms their beliefs'. 

A quick look at this short YouTube clip may help.

Then consider the concept of conflict of interest which may be easy to identify in medicine for example, with concepts like 'Big Pharma' and 'Bad Pharma', which even have their own Wiki pages, but perhaps less overt in Health Sciences and related subjects. 

With those things in mind, here is my tongue in cheek personal take (from the experience of both reading and writing blogs) on a few of the types of blogger you may encounter out there … and some of the factors that may influence them ... Enjoy! 

Meet some of the ‘blogger types’

1.     The altruistic/educational/hobby blogger – Blogs about a variety of topics of interest to potential readership. Evidence based, educational conduit, who likes to hear the sound of his/her voice … Keeps up to date and an open mind, avoids extremism and generally goes out of his/her way to avoid bias, May throw in some controversy for interest, but sticks to honest appraisals of the evidence. Likes a little devilish humour and for folks to read his/her blog. No commercial interests, no adverts, no shop. Altruistic, ego driven, no nonsense profile builder. Moderate use of social media (SoMe) to promote blogs. Checks blog metrics occasionally. Likes to be asked to ‘guest blog’. Secretly hopes for a trip to Hawaii to speak on his/her latest blog topic. Conflict of interest - Nil of note. Has had a book 'in the pipeline' for 15 years. 

2.     Student blogger – Students who (led by their University Professor) have entered the World of blogging, without actually knowing what they have let themselves in for. Main qualities are passion for the topic and enthusiasm. Downfall may be inexperience (blogging), naivety and failure to critique, or cover the topic from a wide and unbiased perspective. May find themselves, unwittingly at the sharp end of criticism from outraged readers. Not always prepared for this. Variable use of SoMe use, that is until they realise blog metrics contribute to their overall assessment mark. Comments are enabled … until they get thoroughly blasted by someone. Not entirely sure ‘exactly’ where Hawaii is, but would love to go. Conflict of interest? ... Actually, the main thing is ... to pass the assessment!

3.     The Snake oil seller – So enthusiastic about their particular brand of ‘snake oil’. They forgot, or chose not … to support any of their claims with even a shred of evidence. They tend to rely entirely on anecdote and personal recommendation from users of the product/idea/treatment technique. Tales of miracle cures are commonplace. Comments are moderated to include more anecdotal claims or gushing personal endorsements. Commercial interests are generally utmost on their minds and they will ALWAYS have an advert for their particular type of ‘snake oil’ on their blog. This blogger, will be targeted mercilessly by bloggers number 5 and 7, generally to no effect (because they live in their own World, or maybe Hawaii). Heavy use of SoMe. The course for this is product /idea/service is ‘brilliant’, said a delegate. Conflict of interest – Zero (there is no conflict, as their sole interest is profit). A modern day ‘medicine show’. Link directly to the 'shop' here. Entirely and unashamedly biased.

4.     Society or organisation ‘news’ blogs – Generally low-key interest/news articles for members. Designed to update folks on the latest development in the field of interest/profession. Tend to report and stick to facts, seldom court controversy and may tend to be a little bland. Media spokesperson quotes some 'evidence', but may not always be in context or entirely up to date (this will be spotted and hastily dealt with by blogger number 7). Low to moderate use of SoMe for promotion of blogs/articles. Comments commonly disabled. Bland content, seldom gives opportunity for bias. Metrics? Hawaii? Humour? Shop? ... Pardon me!?

5.     EBM proponent/Targeted attacker – Wily operator, who picks a specific (often universally disliked target) and exposes it/them and provides reams of evidence to back up his/her claims. The best of these will end up on a TV show deliver a TED talk or get a column in a broadsheet. Heavy use of SoMe to promote blogs. Commercial interests may include books, newspaper articles, TV show appearances, talks etc. Sycophants and wannabees will include them in a Tweet in the hope of a rebound (seldom works). Comments ARE enabled, and this blogger loves to argue the toss with anyone who cares to have a go and often does so with incisive humour or complex statistics. Perhaps a little obsessed and in possession of a large ego. Naturally biased towards own (often populist views) but generally and genuinely supported by the evidence. This blogger loves notoriety. Metrics are through the roof (seldom needs to check) Goes to Hawaii regularly via private jet. Conflict of interest? ‘Pah … call my booking agent, I'm busy working on my next book/TV show’.

       The rest … (Type 5b), may end up looking looking like aspiring wannabees with a particular axe to grind. These yet to be so ‘successful’ wannabee type 5's, are feverishly typing whilst waiting for ‘the phone call’ and busily fending off ad hominem attacks from ‘outraged of Tunbridge Wells’ or assorted trolls. 

6.     The evangelical blogger – Combines the friendly bonhomie of blogger type 1 with the spin of blogger 3 but has a clear underlying mission of promoting a particular product/method or school of thought. May have a track record in peer review publication, suggestive of authority, yet routinely cherry pick evidence, to support a particular view.  Entirely convinced by the sanctity of their chosen path/product. Extremist disciples, lambast non-believers or other 'churches' as unseeing heretics.

Blog comments are ALWAYS moderated and predominantly populated by devout and enthusiastic followers. Humour is not a common feature of their writing. Evidence based, but a stoic adherence to one doctrine/product/method, leads to blogs that are littered with confirmation bias and supported by cute anecdotal stories. Heavy use of SoMe for promotion. Strongly motivated by metrics and sales. Conflict of interest - You can join the latest crusade (in Hawaii) next week, which ironically coincides with their latest blog (submit HERE to apply). Merchandise shop? Click here.

7.     Frustrated, change agent blogger – This passionate and profuse blogger is entirely frustrated by the speed at which his/her profession effects change. Routinely supplies or demands ‘the evidence’, which calls for the immediate abolition of out-dated ideas, methods and products, which have been ‘shown to be ineffective’. Such vigour and attention to detail, means they may occasionally therefore, resemble the internet 'evidence police' or media watchdog. 

    Fierce belief that the only really valid evidence is the ‘gold-standard’ RCT. Particularly adept at highlighting what doesn't work ... but may omit to offer alternatives to the discarded idea/method/product ... therefore run the risk of leading his/her colleagues into an ‘evidence based’, but tool less cul-de-sac. Energetic, challenging and authoritative. Couldn’t make the conference in Hawaii, but hopes to be there next year (recently spoke in Milton Keynes/Basildon). Busy writing another blog in the mean time. Loves Twitter. Metrics matter. Big fan of type 5a.  Ubiquitous. No time for shops, but currently working on a few other conflicts of interest.

NOW it’s time brighten up the academic tedium with a game of ‘Biased BLOG Bingo’ with the blog YOU last read … errr NO, not this one, it is ENTIRELY biased to my point of view!

DISCLAIMER: Bloggers take part in ‘Biased BLOG Bingo’ entirely at their own risk …
This presentation does not pertain to any bloggers called ‘Hamlin’ …or anyone else, it is merely a parody conglomeration of stereotypes. Anyway ... lighten up! 

Grid design MattLowPT
10 points = BINGO (start at zero) 

The higher the score the MORE biased the blog … GOOD LUCK!

1.     Is this blogger a 'snake oil seller'? (Score 6 immediately)

2.     Does the blog contain ANY credible evidence? (Deduct 1)

3.     Is the blog full of anecdote, personal experience and endorsements from users of said product/service/doctrine? (Score 3)   

4.     Is the blog balanced and offers more than one school of thought? (Deduct 2)

5.     Does the blog direct you to ALL of its sources? (Deduct 1)

6.     Does the blog direct you to just the sources it wants you to read? (Score 2)

7.     Does the blog promote ONE specific idea, method product/service? (Score 3)

8.     Does the blog recognise and report opposing views objectively? (Deduct 2)

9.     Does the blog denigrate/mock the ideas of others? (Score 2)

10.  Does the blog cherry pick evidence to support an idea, method product/service (Score 2)

11.  Are comments allowed? (Deduct 2)

12.  Are comments moderated? (Score 1)

13.  Are comments disallowed? (Score 2)

14.  Are the moderated comments predominantly congratulations from ardent ‘followers’? (Score 3)

15.  Is there a SHOP? (Score 3)

Note to BLOG readers: If your favourite blog scored 10 or more (arbitrary unscientific score) ... Just take a moment to reflect on that. There is no suggestion that blogs should not be biased, bloggers write (and sell) what they like ... BUT having a shop for instance, starts them nicely on the road to a pretty impressive BINGO score. However, it is entirely up to the reader to interpret what they see, or to recognise and identify sources of potential bias (if that is, they want to..?) just as they would, if perhaps they chanced upon a copy of the Daily Mail.

As one blogger recently said, "We are all biased" ... it is just a case of how much? So, whilst you may heartily agree with what your favourite blogger says, does or sells, it may be worth reflecting upon their potential for bias/conflict of interest AND how that affects your decision making ... and subsequent actions.

Yes, yes … I know! … I’ll be scoring my own blog later (BINGO!)

Big thanks to Will Self for his inspiration … I may include him in a Tweet (secretly hoping for a rebound ‘re-Tweet’) just before I delete my own Twitter account or become blogger number 4

Author: Alan J Taylor is a writer and critic who thinks about stuff and works as a Physiotherapist and University lecturer ... The views contained in this blog are his own and are not linked to any organisation or institution. Like Bukowski, he 'writes to stay sane'.

You'll find him mostly on Twitter
... that is until, he finally deletes his account, or is 'evidence based blogged' to oblivion. 

Biased blog bingo grid design .... via @MattLowPT 

Thursday, 15 January 2015

10 Good reasons why physiotherapists are perfectly placed to deliver exercise prescription.

A Physiotalk Tweet Chat recently posed the question ... 'Is exercise at the heart of Physiotherapy?' ... and that got me thinking!

So here is my take on that ... written in a mini-blog and offered up as a SlideShare version for those who prefer that sort of thing.

Here are 10 good reasons why physiotherapists are perfectly placed to deliver exercise prescription.

1.    Specific knowledge of exercise physiology and sports science
2.    Specific knowledge of neurology
3.    Specific knowledge of MSK pathology, co-morbidity and disability
4.    Specific knowledge of the respiratory system
5.    Specific knowledge of biomechanics
6.    Specific knowledge of pain science, and the ability to communicate strategies for behavioural change
7.    Specific knowledge of the psychological, mental health and societal  implications of injury/illness/dysfunction
8.    The ability to progress and modify exercise prescription to meet mutually agreed goals/targets
9.    The ability to develop exercise prescription to meet agreed functional needs

10.  The ability to modify exercise prescription to meet the need of all age groups and levels of aspiration.

Question is … Are we using a ‘system based approach' and leading the pack? … or simply too busy sniping from silos?

I have some thoughts about that ... but I think we should concentrate on directions for the future ... for physiotherapy and exercise prescription. 


1.    Step outside your silo ... and lay down your guns! Firing at others is a waste of time and energy ... save it ... or your performance will suffer!

2.    Concentrate on integrating and sharing the knowledge

3.    Spend more time and energy on what DOES work

4.    Consider exercise prescription as a powerful TREATMENT MODALITY

5.    Develop and promote a ‘Systems based approach’ to exercise prescription, which incorporates all of the above

6.    Exercise your minds … Become leaders NOT followers

See a full 'SlideShare' version of this mini blog here

For resources/evidence for exercise and health, together with just a few reasons WHY exercise matters go here.


Alan J Taylor is a writer and critic who thinks about stuff and works as a Physiotherapist and University lecturer ... The views contained in this blog are his own and are not linked to any organisation or institution. Like Bukowski, he writes to stay sane.

You'll find him mostly on Twitter