Going beyond good and bad practice

The idea that one approach to practice is superior to another is a powerful discourse in physiotherapy today.

Last week I was talking with a colleague who thinks of himself as a 'critical thinker', and we were debating the merits of active rehabilitation over passive treatment.  So called 'passive' treatments (some forms of massage, manipulation and electrotherapy, for example), in which the patient has treatment done to them rather than taking responsibility and actively engaging, have been the subject of much criticism in the profession for some time now.

There is, I was told, indisputable evidence for the benefits of active approaches over passive treatment, and that those who advocated for arcane passive treatments were doing an injustice to the profession and holding it back.

Now, you may have sympathy with my colleagues viewpoint, but to me at least, it's not critical.

It's no more critical than the perspective of those advocates of passive treatment who, once upon a time, would have had their own 'proof' of the efficacy of effleurage, grade V manipulations and short-wave diathermy.  Do 'modernisers' believe people in the past practiced out of sheer ignorance or some cultish belief in the mystical properties of their hands?  Do they think that it's only now that we've had access to the 'truth' and that everyone in the past was woefully misguided?  If they do, I would recommend a look back through the profession's history.

Almost exactly the same debate happened in the 1930s and 40s, when group-based exercises were seen as far more effective (and less costly) than the expensive one-to-one hands-on care offered in previous years.  The reason for the move away from passive treatment then was, like now, governed by a much more complex set of factors than the two-dimensional image offered by evidence-based practice.

We like to think that we are slowly becoming more enlightened in our worldview, but evidence all around us point to the fact that we are anything but more enlightened: (Climate change / Syria / Donald Trump / etc., anyone).

No, the belief that we can become more enlightened through logic, reason or research fundamentally misses the point about the reasons why people do what they do.  People don't turn to 'passive' treatments because they're necessarily more effective than a good exercise prescription.  The popularity of various modalities of treatment have waxed and waned throughout history, in large part because of cultural shifts (attitudes towards touch, for instance), economic drivers (funding for certain kinds of treatment), and political reasons (to align a profession with certain practices and 'against' others), much more than because of scientific reason.

Massage may be more popular as a modality now than at any time in human history.  You can find practitioners of the passive arts in almost every town and every country, and passive treatments show no sign of declining in popularity (despite the fact that there is almost no evidence-based rationale for their practice).

Physiotherapists have been schooled to believe that there are good treatments and bad; that logic and reason should be the arbiter; and evidence-based practice is the sword that will cut through the morass of competing ideas.  But a truly critical perspective on this discussion would take a broader view, and see the claims of today's generation of advocates as just another expression of a deeper set of issues affecting the profession, and no more or less enlightened than what had gone before.

The key is, of course, that all practice philosophies are contextual and relative, and no amount of evidence for or against will change the desire of some people to be passive in the face of pain, discomfort and dysfunction.  Are they wrong to think that?  No.  Are we wrong for saying they're wrong?  Perhaps.  But what is this 'wrong' anyway, and who decides?