Thursday Thoughts: Where's the Evidence? | Modern Manual Therapy Blog

Thursday Thoughts: Where's the Evidence?

If you've ever attended an Eclectic Approach course, you'll know one of my "E" points is being Evidence Lead, and not Evidenced Based.

EPB to me, means the Evidenced Based Police... people who troll blogs and social media, start up arguments based on theoretical mechanisms, most of which are entirely plausible and most likely true but their delivery is terrible. Most of us in social media have encountered them, and then they go back to wherever it is they came from and all high five each other on being more informed.

A few quotes from my buddy Charlie Weingroff succinctly state my thoughts on this supposed controversy.
  • The result of your work is the evidence.
  • I subscribe to the Journal of Common Sense
  • You measure something, introduce a variable, and then remeasure to see if a change is made. That's the scientific method in a nutshell - (last one is paraphrased)
Take MDT for example; it is proven to be a reliable method of assessment for the cervical and lumbar spines. Using a repeated motion exam can quickly predict outcomes of a patient via centralization. It also fits into all the evidenced based guidelines on teaching patients self care, independence from passive treatments, and gives some rudimentary pain science education. 

However, it is not proven for the thoracic spine, has only been proven in a few case reports for the shoulder and the knee, yet it works all over the body, makes sense, and teaches our patients to be independent. Who the heck is not going to use it after receiving training in it?

"The result of your work is the evidence"

The EPB are "against" postural correction as well. You may even say vehement... why? Who knows, maybe they're too lazy to sit upright reading all of those journals. Posture is not a root cause of all neuromusculoskeletal complaints, but it matters when it changes a patient's presentation.

I saw a patient last year, with chronic lateral epicondylalgia from her repetitive lab work. After taking her history, the first thing I did was try some posture correction and then overcorrection. The cervical retraction with posture overcorrection eliminated all elbow pain with grip, wrist extension, etc... So despite the "evidence" stating poor posture does not lead to complaints, it is relevant to the case in front of you when you can correct/overcorrect it, and it makes a change in the way the patient feels and moves. It's one of the most simple, empowering things you can teach a patient. With thousands of MDT trained therapists all around the world making similar changes, is not that proof enough?

What happens when you argue with a EBP troll
One piece of advice, do not get into arguments with the EBP, they are myopic and like most internet arguments (or is it all arguments), you'll never convince them.

"Does it make sense?"

Yes, despite what you're told, it can go both ways. You can, and should pick and choose what research you use to enhance your clinical decision making and also still do "non" EB treatments. However, who is to say some technique that works frequently, does not hurt patients, and helps them become independent of you (say, like Mulligan techniques), should be avoided due to the lack of RCTs on it? Remember, according to Chad Cook, most RCTs, at the validation stage (repeated experiment) are not significant the next time around.

A parting thought....Is a personable old school manual therapy clinician who believes in repositioning the SIJ with manipulation and MET, capsule and fascia deformation, "stretching" the nervous system, and still has amazing outcomes, doing a bad job?

Keeping it Eclectic...


  1. "One piece of advice, do not get into arguments with the EBP, they are
    myopic and like most internet arguments (or is it all arguments), you'll
    never convince them."-best quote of the day! loved the blog today...and yesterday

  2. I also loved this post! If only we could get more subscribers to JCS (the Journal of Common Sense)...

  3. Shawn Patrick RiesterJune 19, 2014 at 3:06 PM

    Erson, what was my line that time for the PT who emailed me from Tampa about my thoughts on something: "MY patients don't care how you treat YOUR patients." Some people do LOVE to argue.

    And I feel slight shame. What movie is that capture from?

  4. It's from Billy Madison, shame on you for not knowing!

  5. I agree with Jeffre

    here is my 2 cents

    There is a difference between evidence based practice and science based practice. History shows that if we followed evidence without understanding the science of what we are doing, we would run into trouble.

    For example, evidence showed that bloodletting worked to decrease fever, but understanding science proved that the fever was reduced because of excessive blood loss, shock and etc. Modern evidence based research is showing that manual therapy and therapeutic or corrective exercises do indeed work. But when researchers break it down to it's science, the reasoning for why patients improve are not what the initial evidence based study stated.

    We can take the McKenzie Method as an example as well. when I took part A and B years ago, it was based on the disc model and outcome studies gave evidence that it worked. But to conclude that the patients improved because of reduction of the disc may be in error due to extraneous variables at were not measured that also play a role in recovery. Science based studies have demonstrated that other possibilities may also be involved such as changes in diffusion of fluids, changes in the somatosensory cortex through movement awareness and motor control, promotion of ideomotion to decrease tension in the body, changes in neurotension, improvement of fear avoidance and catastrophization and etc.

    I think a lot of disagreement occurs when people discuss what is right and what is wrong. Unfortunately, if we look at all of the possible variables, we really don't know why a patient will improve. Perhaps it is about being less wrong especially sense most studies (over 60 out of the 70 of the most current articles) show minimal reliability validity of palpation.

    With a patient who improves with repeated extension and sidebend with gentle mobilization, I try to keep my explanatory model in line with the work of David Butler and Lorimer Moseley. I think that they might be less wrong. Since many studies show that OA and disc related issues may not be related to pain. If we tell a patient that "something" is causing their pain, we may be setting them up to catastrophize in the future resulting in recidivism simply because they think something is wrong with them.

    So it's not really what we do that is incorrect. We should keep doing most of what we do. It's the explanation that might need to be modified.

    I've read in your blog multiples times that your manual techniques are getting lighter and lighter. I think that this is following science based practice. More and more studies are showing that there are receptors in the skin rather than deep muscle spindles that relay messages regarding proprioception to the brain. So with gentle skin glides to stimulate slow conducting efferents including feel good-non-noceceptive c fibers, Ruffini's endings, and etc will improve artho and osteokinematics of joints without having to do painful end range grade IV and V mobilization for painful conditions.

  6. Rex, agree 100%, as you should know if you read my blog regularly. I definitely believe we need to update what schools and clinicians are teaching in regards to mechanisms. When almost every school and con-ed series is still teaching mostly mechanical mechanisms, when and how does the paradigm shift happen?

  7. I'm about to link to this blog post. Thanks for a fantastic write-up that echoes my sentiments on this topic.