How to recognise a physio dinosaur… A guest blog by Lars Avemarie

So for my first blog of the year I thought I would continue with my prefered theme of challenging the status quo and calling out the archaic and backward thinking and practices of some physiotherapists. Now when I say me, I mean someone else, as once again I am pleased to give you a guest blog by Lars ‘physio wikipedia’ Avemarie. In this blog, Lars gives us some useful ways to spot the physio dinosaurs who are stubbornly and ferociously holding our profession back and couldn’t do a push up if they tried, and why they often love to continue to promote manual therapy and other crappy passive treatments. So without further ado it’s over to Lars…

How to recognize a dinosaur physiotherapist (or physio guru)

The ‘dinosaur physiotherapist’ is a term coined by Adam in his BJSM editorial to describe the “iconic, influential and idolised clinicians and researchers who, despite a new era in understanding pain and the growing evidence of the biopsychosocial model, still stubbornly refuse to change their methods or mindset, and continue to promote and teach outdated methods of assessment and treatment.”

There is a danger that if we continue to use the same uncritical, unscientific thinking as the dinosaur physiotherapists, our profession will not progress. Fortunately, the lazy thinking that has been characterized by dinosaur physios over the last couple of decades is starting to dissolve, and the new generation of physiotherapists are becoming more scientific and research-minded. However, nothing threatens and scares an old skool dinosaur physio more, than getting their ideas and practices challenged, or their dogmatic practices scrutinised using scientific research.

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But what makes a “dinosaur” physiotherapist, a dinosaur? and what distinguishes dinosaurs physiotherapist from other physiotherapists?

Australian physiotherapist Neil Meigh had a great post on social media recently that can serve as a way for clinicians and patients to recognize if they are dealing with a dinosaur and one and that would serve our profession best by fossilizing as quick as possible.

Dinosaur physios often have vested interests in peddling pseudoscientific treatments, and “quick” fixes for complicated musculoskeletal disorders and/or pain. This is often achieved by them thinking they are realigning subluxed joints or twisted thoracic rings, poking trigger points, or releasing fascia, muscles or even immobile kidneys, all these things are pseudoscientific and based on little to no robust evidence.

Here are 7 fundamental characteristics often seen in dinosaur physiotherapists to watch out for:

Operator, not interactor

Physio dinosaurs see themselves as “operators”, that is someone who can “fix” a patient’s problems or pain. The mindset of the “operator” is that they can, with their superior master/jedi level of skills, often in manual therapy, correct and adjust their patient’s muscle activation patterns, or firing sequences, not to forget the batshit crazy stuff, like adjusting the internal organs of the patient. The implication of this operator mindset is that the patient views themselves as a passive recipient in the therapeutic encounter, and the dinosaur does not recognise themselves as an interactor with another human being.

Showmanship

One thing that the dinosaur “guru” physio often does is showmanship patient demonstrations. Where they quickly change a patients issues on stage in front of a cast of fans and believing followers. One reason that the dinosaur physios are still using the outdated ‘operator’ treatment model, is because it supports and caters to their showmanship nature and large self-inflated ego.

While patient demonstrations can serve an educational purpose, this is not the way the dinosaur physio uses them. These demos are more about them, not the patient, and about the superior results they get with the patient, and it only serves as a means to fuel their larger than life egos.

Anecdotal evidence

The dinosaur physio very often has a pile of successful patient outcomes, that if put on top of each other, could reach the moon. They will be quick to call out weak and anecdotal evidence if they see it presented as something that goes against their own narrative but will reel off multiple clinical anecdotes as support of their own superiority.

As my friend Ben Cormack said when asked why he did not post more personal anecdotes on social media, “What kind of self-publicizing egomaniac would shout about his results”. Dinosaur physios also very conveniently forget that “outcome measures measure outcomes, not effects of intervention” (Herbert et al. 2005)

Toolbox thinking

The dinosaur physio is often in a never-ending search for the next best tool to put in their clinical toolbox. The mindset that fuels this thinking is the more tools they have in the clinical toolbox the better they become. They also are senior riders on the modality rollercoaster, having taken multiple courses, often on very dubious modalities thinking this gives them some kind of superiority to a normal physiotherapist, with fewer courses and less experience.

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As noted by my good friend Dr. Silvernail “A toolbox is full of products without an underlying process – and that does not lead to a defensible and consistent approach that handles complexity well.”

Magical quick fixes and biomechanical errors

The physiotherapy industry has a long history of trying to find the magic ‘technique’ or intervention as a quick, easy, simple solution to the complex multidimensional problem that chronic pain is. Something Prof. O’Sullivan has a great editorial about (O’Sullivan 2012)

These magical quick fixes are typically only supported by fantasy like explanations, and erroneous evidence at best. The dinosaur physio has not read up on the current scientific research and therefore has not come to the conclusion, that there are most likely no quick fixes to the complex multidimensional problem that chronic pain is.

But because the dinosaur physios business model is based upon serving magical quick fixes as a simple neat solution to chronic pain, they ignore the mounting research that notes that pain is a “multidimensional experience produced by multiple influences.”  (Melzack et al. 2013)

The I’m offended tactic

Physio dinosaurs will often claim to be offended or insulted by others critical views or the way they have expressed them. They will also often be “offended” if you try to show them evidence for the unsupported claims they make about their methods. This is a tactic that seeks to withdraw the focus from the fact that they often have no evidence to support their claims. Calling out a dinosaur’s flawed clinical reasoning will likely result in them calling you unprofessional and result in childish behaviour, missing the point at issue.

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Pain is a thing

The dinosaur physio has often conceptualized pain as something that is in the body like a kidney or patella, but pain is not a somatic entity. This erroneous belief serves a very practical propose, that it empowers the dinosaurs to attack this “thing” (called pain) with different modalities and quick magical fixes, forgetting that pain is an experience. As is noted in the very definition by IASP, “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage”.

Dinosaur physios can often be successful and reach a “guru” status if they have a particularly appealing narrative and intriguing or plausible explanations. An important factor in this is that dinosaurs can be very hard to spot, for a client or young physio, because it requires a great deal of experience and knowledge of logical fallacies to spot their flawed arguments.

We must also be on the lookout for the new “evolved’ dinosaur physio who will still do all of the above, but under the guise of sciencey-sounding words and phrases, like “evidence”, “consensus”, “neuromodulation”, or “contextual effects”. `However, when looking at their work you will see that they have not really evolved one bit, merely learned some new fancy words yet their actions and methods are still the old and dogmatic ways of the past.

Due to the fact that it is hard for most health professionals and patients to spot a dinosaur physio, I am hoping that this blog, Adams editorial, and Niel Meighs social media posts can serve as a way of others recognizing the hopefully soon to be extinct dinosaur physiotherapist.

 

13 thoughts on “How to recognise a physio dinosaur… A guest blog by Lars Avemarie

  1. The concept of ‘dinosaur physios’ having a big ego is probably true and you’re right that it is sometimes ‘all about them’. But blogs like this can also be seen as egotistical. If you want to make the world a better place, say things in a way that is palatable, that people can take on board and change, without feeling attacked. Otherwise you wont make a difference, you just end up being popular with like-minded people and never prompting any change.

    • @Julia While it is always the possibility that those who create an online presence may be prone to narcissism and egotism, it depends on many factors. But, to use the argument that hurt feelings should be sufficient reason to avoid telling it like it is, sans bullshit, isn’t going to cut it. If the profession doesn’t come to terms of its own unwillingness to grow the ‘f’ up, then I give it a decade before it becomes unrecognizable as a legit health profession.

      By definition, criticism isn’t “palatable”. It’s not supposed to be. It just is.

      On this I will side with Adam.

  2. A little humility would go a long way. Of course things evolve and certainly the history of medicine and PT is full of silly BS that couldn’t stand up to harsh light of evidence. Here’s my prognostication(for what it’s worth, about as much as your rant). Pain science and education, that terribly important and oh so trendy approach du jour, will settle down and(maybe) find a place in the care of a small subset of persistent pain patients who may find some comfort in a different way to conceive of their pain. The challenge is in maintaining some perspective and to accept that just maybe “they” have some good ideas and “we” can’t possibly have it all figured out. So it goes.

      • Pain Science is a myth, perpetrated by young dinosaurs. Sorry, but whenever I smell a whiff of righteous certainty proffered in these kinds of discussions, I am inclined to suspect little has changed. Those dinosaurs live inside each of us, more than happy to pop out as our personal crusader.

        The issue in the larger context is that PT is vulnerable to exhibiting the kind of ‘upbringing’ that leads to narcissism. The gurus are made possible by enablers in the ranks who refuse to engage in critical thinking for fear of upsetting Mommy Dearest (the archetype), all part of an authoritarian (vs authoritative) organizational culture. Sadly, the staunch refusal of accepting that the profession is stuck in the 1960s and is a place of comfort for far too many, never seems to get much time in discussion.

        Another interesting post Adam, Thank you!

  3. I’m not standing up for these “dinosaurs” per say. Yet if clients find the methods effective in increasing QOL, decreasing pain. Etc. Why is this not effective? I get your target is the ego side of the dinosaur so why not be more clear on that in your topic?

    My biggest concern with this article is there is no positive recourse or direction as to which treatment modality or viewpoint is “effective” yes biopsychosocial model is the lens to operate from, and yet I feel even this has become a name drop and when questioned many people do not even know what this means!

    So I challenge you to balance a time well spent righteous article with a finishing paragraph that enlightens and inspires us all toward greatness and effectiveness, rather than demonize methods that are likely helping thousands, in favor of attacking the ego of the dinosaur. Egos require tact, not attack. So if this is not your own ego who wrote the article, I trust you will find it easy to promote an excellent follow up!

  4. I am a nobody. But as is my want, like yourself I can have a view and Lije yourself I have no fear in voicing it.
    I abhor pretentiousness. I also abhor anyone who doesn’t have the nerve to cite the centre of your attention -your dinosaurs. Who the fuck are they? You haven’t actually got the balls to say what you mean and the effect of your outburst is lost. Your blog is a meaningless monologue of an also ran therapist……..

    • Wow, talk about some unresolved hostility issues. Is that how you operate then, by projecting your inner vomit onto others? Madonna had a hit song a long time ago called ‘Borderline. I’ll remain polite and leave it to you to figure that out.

      Yikes!

  5. Cherry picking evidence to suit ‘showman’ theory, finding loopholes in published articles:’ poor quality RCTs ‘ (no surprise then similar systematic reviews outcome by desktop physio research for yet another publication to credit)decent clinicians obviously wary of venturing into research, (can you ever get a pure RCT?)we got mortgages!!to pay and therefore never challenge status quo so as not to appear as outcasts. This comes from a physio who graduated 18yrs ago, so I am a dinosaur hehe. I loved the blog.

  6. A big, fat AMEN to this blog post. Thanks Lars and Adam (and Greg) for keeping me sane. I will go as far as to say that without Meakins I would no longer be a Physiotherapist.

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