Some are Always so Certain and the Wiser so Full of Doubts: The Impact of Bias on Best Practice in Physiotherapy

In our last blog we looked at the strategies we can use to develop athleticism in our young athletes. We highlighted the need for long-term engagement of both the coach and athlete to develop the various physical and psychological qualities, in order to optimise the development of the qualities required to develop ‘athleticism’. There are lots of variables in this process, interacting at different stages to add chaos to the journey. Thus, it is our job to utilise our skills and best practice to control as many of these variables as possible and gain the best outcome for that individual. In this blog we are going to explore how certain we can be about some of our commonly held beliefs in the field of physiotherapy.

We all have a bias. As such, we will gravitate to the theories and opinions that we find fit our own narratives. Sometimes we even label our biases by declaring our alliance with a method, theory or modality e.g. manual therapist, exercise therapist or McKenzie therapist. This allows us to gravitate to others with the same biases, forming a bond as part of the same tribe, and openly advising others where our preferences reside. This tribalism can be valuable providing reassurance that there is certainty in the methods used to help our clients, patients, students get ‘better’. However, if we are too immersed in the culture in which our bias resides, then we are blinded to the development of other practices which other ‘tribes’ may provide.

Once we can be comfortable enough to challenge our biases, we are then set a further challenge of navigating the evidence base to further enhance our practice. A lot of what we take as fact has not been tested sufficiently to be irrefutable, therefore we need to keep an open mind to how this may be challenged in the future. This is the nature of science. However, a lot of what is seen to be ‘the way’ in physiotherapy does not have it’s grounding in science. Take the popular concept of trigger points. The widely accepted theory of these being ‘muscle knots’ due to a local area of inflammation and reciprocal localised tightness has filtered it way into the common understanding and perpetuated a false narrative around some types of muscle pain. In some cases, in the absence of a clear diagnosis may lead a practitioner to scape goat trigger points as the source of pain. When we delve deeper into the theory, we realise that this theory was never initially tested, just accepted and treatments developed to assist in the removal of the troublesome trigger point. Much later, professionals began to challenge this theory resulting in this assumption being refuted. Currently, we are still not certain what this phenomenon is physiologically, however we are able to prove that trigger points are not what was widely accepted they were, and therefore understand that the treatments traditionally used to address this issue may not be the best way forward.

Even when we consider our fundamental assessment techniques like manual force testing. The gold standard currently is to use handheld dynometry to assess force production vs traditional ‘feel’ methods. We utilise limb symmetry index to quantify ‘normal’ in conditions affecting a single limb or area, however to my knowledge there is no normative data for any population for any limb which we can compare scores to. This begs the question in our rehabilitation as to how strong is strong enough? Or how strong does someone need to be to be able to reduce injury risk or recover from a certain condition. Again, even in this fundamental area there are unanswered questions affecting our ability to be certain about our clinical judgements.

There are vast areas of our practice that we need to view with a healthy scepticism, in either assessment or treatment. Often these things go hand in hand. There will always be a level of uncertainty we need to be aware of in our practice, even if the research all points in one direction, the sands may shift around us challenging our biases and practice. We must be comfortable enough to be aware of our bias and allow it to be challenged, this is ultimately how we will grow as healthcare professionals.

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