Yesterday’s blog on research in sports got an interesting response, from nodding agreement to being told it was “utter crap!”

The critics said I was talking up the “personal anecdote” and that without research we can’t know about “causal inference” i.e. what really has created the change we observe. Two good points, to be fair.

I’ve given it some thought and I stand by what I said, research is part of the reasoning process and not all of it.

In an ideal world we’d have conclusive research that had reached consensus on what treatments are most effective. We’d draw on that research and have truly evidence based practice. In reality there are few areas where such consensus exists. You’ve seen with my recent post on glucosamine and chondroitin, there are studies for and against and you take them all in to your reasoning process.

In time maybe a consensus will be reached on more topics. Only fairly recently have we reached agreement on the things we’re actually treating. We’ve discovered that there may not be inflammation involve in tendonopathy, that ITB friction syndrome may not even involve any friction and that we can’t diagnose around 85% of low back pain! How can we approach consensus on treating these areas when we aren’t really sure about the underlying problem?

I had an interesting discussion with @NeilOConnell about this on Twitter. Some areas we have a consensus, an agreement on best practice, such as early management of low back pain – we know it’s best to stay active and avoid prolonged bed rest. The same may be true for tendonopathy – a graded eccentric loading programme is generally considered a sensible approach. In some areas though we appear to be a long way from agreement. Look at these two papers on resistance training; The American College of Sports Medicine (ACSM) have produced recommendations based on over 200 research papers, despite this their findings were heavily ciriticised. Even if we use the ACSM’s guidance, it’s based mainly on healthy individuals, can we use that for those with injuries? So what do we do then? This was part of my point yesterday, in many areas the guidance from the research is unclear and we have to use it with clinical reasoning and experience.

Another issue here is biology isn’t everything. In recent years we’ve realised that biological changes aren’t always consistent with symptoms. Around 50% of people have a disc bulge on MRI without symptoms. X-ray changes with arthritis in the knee match very poorly with pain. We’ve developed a biopsychosocial model to help us see that the way a patient thinks, feels and behaves affects their symptoms and that work, lifestyle, relationships etc all play a huge part. Some research is based in this field, but a lot of research is based more in a simplistic medical model – diagnosis + treatment = outcome. There are some amazing studies on Psychoneuroimmunology – how stress, mood and how we think actually directly affects healing. We know that beliefs play a big part too, especially in pain. It’s not easy to assess these factors and include them in research but we know they can play a part. This all comes back to my points yesterday on assessing each individual and seeing how complex the decision making process is and using guidance from the literature where possible.

I’m glad to see I’m not alone in thinking this, fellow sports physio @AdamMeakins has written about it today. I must also give him a great deal of credit for sending me this article by Hanson et al. 2012 in the British Journal of Sports Medicine which neatly sums up what I’m trying to say.

They comment on the complexity of the situation and how people’s “natural, physical and social environment” influence each other leading to poor translation from research to practice, taking a quote from Green (2001),

“Where did the field get the idea that evidence of an intervention’s efficacy from carefully controlled trials could be generalised as best practice for widely varied populations and situations?”

They talk about the importance of expertise, acknowledging the role of experience,

“However, there is also a need for better translation of evidence from practice into research…perhaps the real barrier is not lack of understanding, but a failure to listen! Good communication, good translation and indeed good research are necessarily a dialogue, a multidirectional conversation in which everyone’s contribution is valued. If we could find the humility to listen we might be surprised to discover that policy makers, practitioners and the sporting community have valuable expertise that can enhance our research by making it more relevant, more practical and more applicable in the real world”

According to my stats I’ve seen over 5000 patients in a career spanning 10 years and multiple Physio departments both in the uk and abroad. Should this stand for nothing in my decision making process?

Hanson et al. 2012 conclude with this,

“Injury prevention research that does not connect with the practical realities of implementation and adoption, and does not build the consensus needed to ensure effective implementation, will not prevent injury or improve health”

So here I am, squishing the lid back on my open can of worms…my final point comes back to my point yesterday, I am not saying we can ignore research. I acknowledge it has a vital role but it is part of the reasoning process not all of it.

From Hanson et al. 2012

When I get some time I will try and reference some articles talking about things like is there friction in ITB syndrome and diagnosis of LBP…just haven’t had the time yet today!…

 

3 COMMENTS

  1. Excellent post Tom, just wanted to add a different perspective. Research should always play an important role in treatment, however experience & knowledge have to play a role too, especially in situations where you are on the leading edge of discovery. Rarely are new treatment methods the result of waking up at 3am with a ‘Eureka’ moment, but rather from a practitioner or researcher noticing something during their course of practice (i.e. anecdotal) that sets off a new way of thinking. Obviously at this early stage there will not be any proper research to prove what they are observing, so does this mean that they should abandon the idea until there is a healthy mountain of peer-reviewed research that confirms their suspicions? Obviously not, they should pursue their idea assuming they are not risking or causing harm. Conversely, it doesn’t mean that they should take their ideas and anecdotal evidence, and promote it as fact or a cure… and haven’t we all seen enough of that – hello latest fad diet!!

    For our knowledge and understanding to evolve we have to explore these new treatment options, but do so in an intelligent manner. I think what is vital, is that the dialogue be transparent about exactly what evidence is available, and then use critical thinking to examine it closely.

  2. Great post! And so true. My favourite anecdotal treatment is mulligans. His book states that he “tried a lateral glide to aid Achilles pain” (taped) it reduced the pain “so I tried it on a hamstring strain”
    Ergo- I tried something I work so I tried it on similar things, for the rest of his “book” that is how you treat soft tissue lesions to aid pain relief.
    I actually use this as an example for students/NQPs when they ask about trying a treatment technique or rehab idea. It’s the use of clinical knowledge a bit of “give it a go”, and tbh I sometimes feel research is behind the clinical and practical application of Rx rather that leading it.
    A good practitioner will always use all of their senses as well as all of the evidence!
    Ps my quotes from mulligans may be paraphrased (its the original one) but ill find it today and tweet a pic of it – sad as it is its a enjoyable book to read 😀

  3. excellent summation tom. I would be slightly worried been treated by a practitioner who blindly follows a piece of research without blending in some personal skill and judgement of “real world” application. First hand experience of a subject (and this applies to any vocation) can be greatly improved with added theory but never be replaced by it!

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