I can both love and hate twitter at times, but it often does give me some ideas for blogs, such as this one which I had no plans to write until certain events unfolded recently over what I thought was a simple helpful tweet I posted on the latest NICE guidelines for low back pain here. The full guidelines are freely available here. However, this tweet soon created a lot of interest and some surprising and frustrating accusations of my deceit, distortion, and general skull duggary.
Now I often get accused of having ulterior motives and hidden agendas by many people when I question or challenge stuff. These accusations range anywhere from me being against all manual therapy and how I think it should never be used, to claims that I think the physiotherapy profession is completely worthless, and even accusations that I am only ever critical or skeptical to create attention for myself and to promote and feed my own ego and courses.
Usually these accusations don’t bother me, as most who throw them at me are simply trying to detract attention away from the point at issue I am raising, which is usually around some exaggerated or ridiculous claims about some other shitty course, crappy manual therapy technique, pissy rehab exercise, or a bull shit machine that goes bing.
But when a colleague like Alan Taylor, a fellow physio, university lecturer, cycle enthusiast, and skiffle band aficionado whose opinions I usually tend to respect accuses me of having a hidden agenda, deliberate deceitfulness, and distortion of the facts to suit my own paradigm and personal gain, I need to reflect, take stock, and consider what exactly is my agenda?
It’s no secret…
Well it’s no secret that I think my profession has some rather big issues, in fact I think it’s got some bleedin’ huge issues, and I have tweeted and blogged about them many times before. For example, I often question if our profession actually does much to help those in pain or with disability. I question if too many physios are focused on the short term, quick fixes to consider the bigger more challenging issues of poor lifestyle and habit choices, low physical activity, and reduced tolerance to pain, and other stressors.
It’s no secret that I think physiotherapy is surrounded by a lot of over complex pseudo science and is too dependant on passive interventions, particularly manual therapy, electrotherapy, and needles. It’s no secret that I think physiotherapy is a fad driven, guru worshipping profession that in the majority doesn’t think for itself. It’s no secret that I think physiotherapy has an archaic, hierarchical, and dogmatic infrastructure with some of our leaders hopelessly out of date and out of touch. It’s no secret that I think our profession has an academical/clinical divide that doesn’t readily promote or welcome equal collaboration, critical thinking, and open discussion from everyone and anyone, despite lip service given.
So I think my ‘agenda‘ is and has been pretty clear for a while, and I will continue to highlight all of the above issues in an attempt for us to ultimatley be a better profession, to become better at helping those in pain and with disability bulid resilience and self efficacy that will optimise their function and mobility. That in a nut shell is my agenda!
Basically I critique and challenge a lot of what occurs in physiotherapy, not to bring it down, but because I want it to be better. Despite accusations I do love and respect my profession. Ok it frustrates the hell outta me a lot of the time, but I think when done well, physiotherapy (and all the other therapy’s) do an amazing job in helping people and society, and I do try to promote the good it can and does do, including these recent NICE guidelines.
Riled and pissed off!
So i’ll admit that Alan’s recent accusations of me deliberately twisting and distorting these guidelines to suit some other agenda has surprised and riled me, and then to see the usual manual therapy advocates and their sycophants, many of whom I have had ‘debates’ with before, get all excited and jump on the back of this discussion and use it as an excuse to retweet away and promote their own brand of shite also pisses me off.
Now as much as I can work it out, Alan’s angst towards my summary chart (see below) seems to revolve around two main issues. First is me using the words recommend and offer on my summary chart rather than using the word consider as stated in the guidelines. And secondly me saying ‘do not use manual therapy without exercise or education‘ rather than ‘do consider manual therapy but only with exercise or education‘ as stated in the guidelines. Allegedly Alan thinks these subtle changes and emphasis are deceitful, misleading, but also a sign of my genius, and that his amended version is the ACTUAL guideline key points and has #NoBias.
Well first things first, I simply think Alan is splitting hairs for what ever reason, and lets not forget that everyone has a bias, a stance, an opinion, an interpretation, and #NewsFlash they are not going to always be the same as yours. Secondly I don’t know about you, but I can’t see any genius at work here, rather just two people, with nothing better to do, arguing the toss about saying the same things differently. Personally I can not see any significant difference between saying recommend, offer, or consider an intervention. If anything ‘considering‘ as stated by NICE could be interpreted as to be done in isolation by the therapist, whereas ‘offering‘ or ‘recommending‘ as I state implies involving the patient more in the decision making process.
Do or do not?
As for saying do, or do not use manual therapy, with or without exercise or education. Well again you can argue the toss as much as you like, they are simply saying the same thing differently again. OK the emphasis on do or do not is the key difference here, but as I’ve openly, clearly, and transparently stated many times before I do object to the over hype, over use, and over reliance on all manual therapy by physiotherapists, especially in low back pain, which in the grand scheme of things offers very little other than some short lasting, small pain reducing effects, for some, and lets not forget it also has many iatrogenic risks as well.
So again I will be clear and state that my emphasis/bais is not to routinely offer manual therapy to patients, and I guess this is why I worded as such in my summary chart. But to state this is for my own benefit or gain is just ridiculous. Do people really think I gain benefit from or enjoy finding ways to deliberately antagonise and irritate the skin draggers, fascial releasers, and joint crackers out there, enduring their persistent whining and moaning about how unfair, mean, and closed minded I am… Well ok I do a little bit, but seriously it ain’t all a barrel of laughs I can assure you!
Also just because I am not an advocate of manual therapy it does not mean that I think or expressly state that it has absolutely no place or benefit for anyone at all. Believe it or not I’ve used the odd bit of manual therapy from time to time… I used some in November… in 2009… I pushed a stiff shoulder joint backwards a little bit… it kinda helped… I think… for a few minutes!
However, joking aside when I do use manual therapy, just as the guidelines state it most certainly is only ever with exercise or education, and only because the patient has expressed high expectations or preferences for it, and only then if I think it will not cause a loss of self efficacy, or develop a reliance, or reinforce any false or negative beliefs.
I personally think the recent NICE guidelines for low back pain and sciatica are a triumph for sicence and evidence based practice at last, and all those involved with them should be proud. I’m also glad that this little spat with Alan, and these summary charts of ours has perhaps made a few more people go and read them. I think they offer a clear, simple framework for healthcare professionals to follow when dealing with patients with back pain and sciatica, and I still think my summary chart is a fair interpretation of the key points they make, but hey i’m biased!
Lets also not forget that these are only guidelines, and so are going to be open to everyones interpretation. Exercise advocates will focus on and emphasis the exercise bits (just to be clear again, I’m an exercise advocate). Manual therapy advocates will focus on and emphasis the manual therapy bits. Psychological advocates will focus on and emphasis the psychological bits. Acupuncture advocates will focus on and… oh hang on… no one really cares about what they think any more!
Finally, I will once again declare my preference and biases to all who care to read or listen to anything I have to say, that I will always be an advocate for, and will always promote active and educational interventions over any passive ones. And unless strong robust evidence tells me other wise, I will always continue to steer people away from all the passive interventions, such as manual therapy, electrotherapy, needles, tapes, braces, corsets, injections etc and direct them towards increased physical activity, behaviour and lifestyle changes, and ultimately self management.
And I will never, ever apologise for this.
As always, thanks for reading