What Evidence-Based Practice Gets Wrong | Matt Low

Welcome back to the Modern Pain Podcast. This week we're joined by Matt Low, a physiotherapist researcher, and PhD candidate whose work lives at the edge of what it means to know something in clinical practice. This conversation has really been sitting with me since we recorded it. I went through my manual therapy phase in my evidence-based practice phase, and both of them really hit a wall with the complex patients who I felt I simply just wasn't helping. Matt has a framework for why that happens and it starts with a question. Most of us never ask what counts as knowledge in the first place, we dig into something he calls epistemic fluency, the ability to navigate between different forms of knowledge depending on what the situation actually calls for. We talk about Aristotle in ways that's useful for a Monday morning clinic, matt walks through a study discussing a back cafe versus circuit training that will challenge some assumptions you didn't even know you were holding. Part two is coming. This is part one. Let's get into it.

This is the Modern Pain Podcast with Mark Kargela.

I'd love if we could talk about,'cause I think there's some assumptions implicitly we make as clinicians that we don't even realize we're making. Um, so I'm wondering if we could kind of unpack a little bit about what it means. Like what is true knowledge and what have we considered to be true knowledge and how, what are the difficulties with that that we, we face as a clinician?

So I think why, why this is important is that there are some, as we practice, there are some ways in which we think about how we treat our patients, what we think is best care. Um. That fall short sometimes. So, um, for example, if we think about David Sacketts, um, you know, evidence-based practice model where you combine things like, uh, best of the research evidence, uh, the clinician's, uh, expertise and the patient's values and interests, or sorry, preferences. The coalescence of those things is really difficult to unpack. That's why when we think about knowledge, we've gotta be thinking about it in much more broad ways. What, what can happen is that knowledge becomes about what is seen as more legitimate than others. So, um, that's where knowledge is. Socially and materially grounded. What do I mean by that? It's the idea of that there are some forms of knowledge that are more legitimate than others, and this creates attention. So if we take David Sacketts, um, model, which I think the audience will know very, very well, it's what we've been taught. Um, and I would go so far to say, is it's, it's a challenge in the Biosocial model and some of the models that we apply is that, um. When we try to understand evidence-based practice in the center of those three different forms of, um, I guess values, uh. There will be some kind of hierarchy about what is seen as the most legitimate and, um, often the most legitimate form of evidence in Western healthcare. Uh, for lots of good reasons. I'm not saying this is good, bad, or indifferent, but I think it can be limiting is, uh, usually quantitative forms of evidence. Some research which is based on quantitative data. Um. Often that quantitative data comes from population studies, which is absolutely fine. It's good to get a general idea, but there's often a tension when applying that in context and there doesn't seem to be much. Uh, there's been lots of conversation around these kind of topics, but often when we look at course programs. Educational programs where people are applying knowledge in practice, in context, this kind of tension isn't necessarily discussed. And what's easier for us to do is to say, actually, this research study suggests this, and this research study suggests this, and that's fine. But everything has its limitation and that includes, uh, what we can, what we consider to be knowledge in the first place. So, and hence I've got a very different. Perspective, I'm not saying it's right. Um, perspective on, um, how we have to, in my opinion, how we might be better off thinking of knowledge as pluralistic, as many, taking many different forms and it not necessarily having a hierarchical base. And I can explain more about that if you need to.

I like what you said because I, I do agree, and I've been in this trap as a clinician where I, there was a period where, how I was taught in school with manual therapy and it was gonna be like I was gonna figure out this complex thing that is pain with my hands. You've, if you've listened to a podcast, you know that story that fell flat and it became a very kind of a. You know, one of those like, am I cut out for this? Right? This existential crisis we often have in our profession. Research was my answer to that. Like I had evidence in motion at the time was the, the provider of the fellowship. So I was like, oh gosh, well here we go. I got the answer. It's gonna be the research, right? It's gonna tell me what to do, I'm gonna do it, and I don't have to feel inferior with this stuff that I'm just not feeling with my hands. And we know there's limitations with that for other reasons. The research then fell flat too. Um, and because you see people, and, and I think I'd love if you can unpack a little bit more about this difference between how we collect knowledge in. You know, this, you know, way of randomized controlled trials means standard deviations and population statistics. This, um, different way of looking at how we can at, uh, find out what the truth of of things are. Versus the n equals one situation. And that's one of the big things I know cause health was something you were involved in. I I, that was an amazing movement that kind of really got to the crux of this matter of like we need to understand the n equals one is different than the research study where NS are much greater and sometimes aren't representative the unique n in front of you. So I'm wondering if you could speak to that a little bit.'cause I think that's. One of these things that I think still, and I see like the Instagram posts of look at this research article or look at this research article, and I, I do those a bit as well, but I think. It needs to be in context, right, of how we ascribe that to that and equals one situation more. If you can speak to that a little bit more.

So it's, it's important to, to describe n of one means lots of different things. And so I'll, I'll, uh, kind of unpack that first. So. N of one studies is a legitimate form of research methodology, which is actually a really, really, it's underutilized, but it's a very legitimate form of methodological inquiry. Um, but n of one can also be used in a sense of a. My experience as a clinician, which is not what I mean by NF one, my NF one experience. That's not what I mean by NF one. And also NF one can be used as from the patient's perspective. Like, okay, so the patient's, uh, individuality their uniqueness, um, and reducible to that and that alone. I think, um, when I'm talking about n of one, I am talking about the confluence, the coming together of all of the various forms of, um, information that met that we hope to coalesce and cohere coherence, I guess. Around that particular thing that we are trying to support, which is the patient. So if we talk about n of one being the unique patient, it's more akin to that as opposed to to the N of one, meaning the patient's subjectivity in and of itself. So I think that's important first to think of. So when, when we start thinking. One and, and patient uniqueness. I think, um, the ways in which we can apply different forms of knowledge to support that patient, um, comes from yes, it can, it, it's basically tr imagine that you've got a map and you need to look at the territory and map out the terrain. So the research evidence might create a map. It might even give you some grids. It might give you some coordinates, but it doesn't tell you how to navigate that particular environment. If we zoom in a little, we've got the pa, we've got the clinician's own, uh, thoughts, feelings, beliefs, challenges, expectations, and we've got the patient's experience, the history, their knowledge, the thoughts of things, beliefs and behaviors. And all of those things kind of coalesce. And I think, um, and I will kind of, I, I'm afraid I will have to get a little bit philosophical in this, but in order to bring that together, I think it's quite nice if we, not to describe them, sorry, to describe them as, uh, different forms of knowledge, but to see them as something that comes together. So there, Aristotle describes different forms of knowledge. I'm gonna talk about just three. He'll describe knowledge as a pest may, which is knowledge is facts. He'll describe knowledge as teche, which is, um, to do with, uh, knowledge as a tacit form of knowledge. It's a, it's a form of, um, I'll give an example in a second about what they are. I'll give examples of each. And then there's esis, which is, um, the wisdom, the practical wisdom to do the world. To do the right thing at the right time, in the right context and the right situation. So put differently. The EPIs A is the what, the um, the TechNet is the, the how and the Resis is the why and when. And we've gotta bring those, all those things together. Um. To, to, I think, operationalize clinical reasoning in a way that is far more dynamic and situated because I think there is a risk of us deferring to a particular form of knowledge'cause of its social legitimacy. Now that might be, and then, then it becomes a dichotomy. Then it becomes something that is either this or that. And we see that everywhere. Uh, hands-on, hands-off, uh, exercise and hands-on. Uh, you know, um, we think of it in terms of biomedical and psychosocial. We, there, there is a tendency to, to kind of. To create a dividing line. And it's that things are seen across these different planes. And I think utilizing, and, and this is a paper that I'm hoping these gonna be published soon. It's in, um, peer review at the moment. It's a capacity core or a concept called epistemic fluency. Epistemic means, um, to do with knowledge and fluency, you know, like language so you can a fluent person in language, not only within the language, but between languages is a person who's able to speak articulately in the native language, but also be able to understand other languages and be able to work in between those things. So I think we need to cultivate, uh, professionally, um, epistemic fluency. Epistemic fluency is a way in which can bring these often competing forms of knowledge together for the right context. And I think that's particularly important as we reach situations associated well situations. We are in it at the moment, we, you know, where ai, the big digital disruptor is going to really transform, um, healthcare practices. I, and I don't mean that in a good way or bad way, I just think it's going to radically change what we do. We can get into that as well. But essentially that's what I'm talking about when I talk about different types of knowledge and the kind of capabilities that we need to have as, as professionals.

And you speak to the fact that there's some forms of knowledge that have been more legitimized based on probably some systemic drivers for that. Right? Because there's this, you know, we have healthcare systems that want. Things to be efficient, right? And if we have statistics that can guide, you know, masses, amounts of decisions that hopefully can equal a lower cost in a healthcare system, that, and, and again, I I, as you've pointed out, there's not necessarily, that's necessarily terrible, right?'cause we need guardrails on what we do.'cause we don't want people way off in left field practicing all over the place.

Absolutely.

So I, there can be some, you know, legitimacy to that approach. So I don't, it's not that that's not helpful, but. Like you said, that has gotten so weighted in our, in our healthcare systems, that it's the, and it's the whole cry we have here is bringing the humanity back to healthcare.'cause in, in that situation, it seems like we almost reduce people to statistics and, and, you know, clusters of symptoms and, and different things. And we, we lose that human piece. And especially as we start then. Recognizing what science is telling us is involved in a pain experience. It's a very complex interaction of a lot of things that requires a lot of different components of knowledge, like you said. Uh, can you speak to a little bit of that kind of pull that kind of pushed us into this prioritization of that type of knowledge, this kind of, um, empirical, you know, positivist type look at knowledge acquisition and, and kind of how that maybe left that, that. Subject subjective knowledge Yeah. Of, of a patient kind of behind.

I might speak to some of the history of that, although I'm not a particular authority on the, on the topic area, but I would say that one of the, uh, challenges that we have, and I haven't got anything against research-based forms of knowledge, it's absolutely imperative and important that we have it. Um, but say. Uh, let's concentrate on the quantitative forms of, um, research methodology. By its very nature that if studying populations, which gives us a map, but not necessarily the terrain of the patient care, uh, of the patient caseload. It's gonna create a u-shaped curved, uh, where the most frequently observed phenomena is gonna be the most accepted. It's gonna be that in the middle of the U-shaped curve. And the challenge is that, uh, the challenge can be that the patients that we see occupy either side of that U-shaped curved. Um, there's a, there can be an inherent bias. This isn't the case with all research. Of course it isn't. But it's important for us to look at the, say for example, the subjects, uh, that are, uh, analyzed in this and, and the methodology. Where a lot of the early manual therapy, um, papers, for example, the clinical prediction rule stuff that, uh, I think it was Tim Flynn. Um, it was lovely bits of research, but they were inherently biased. They were done on military fit and healthy people who had acute episodes. And this isn't reflective of a lot of the patients that we see every day in practice. So, um, so, so first of all. When we talk about certain population, quantitative forms of data, we've got to recognize where is the person who we are seeing or the population that we are seeing. How reflective of is that person or that population of that, of that, um, of, of that research data. Going back to some of the history, why do we think that positivist positivism was so popular? I think we could possibly go back to the enlightenment and we could go there. Um, but essentially the quantified body we're seen as a legitimate form of practice in biomedicine. And we as physical therapists, uh, have allied ourselves with medicine. And that's given us a lot of professional legitimacy. And so I'm, I'm not trying to, um. Speak negatively of that. I think, you know, we are sitting here, uh, in a very privileged position because of, uh, historical allegiance to medicine, but there is a, a particular way that medicine views the body and um, uh, the historical view that medicine has viewed the body is that of something that's reducible to parts. Um, and if we fix the component parts, we fix the whole. Very helpful for certain healthcare conditions. Uh, so, you know, uh, communicable disease, we've done exceptionally well with that, but that's no longer our, uh, prime complaint or prime concern. People are living longer, but they're possibly not living. Better. And so non-communicable disease, and this is where physical therapy definitely has a part to play for the future, regardless of where AI takes us, there will always be a place for physical therapy. I think how it goes, which we might enter into is different matter, um, but ultimately, um, the. The view of the body in that sense made us or channeled us towards quantifying, uh, various things in certain ways. So I think there's a kind of historical, uh, and legitimate social way in which our allegiance to medicine has kind of created that kinship and the ways in which we've seen, um, seen the body in the sixties and seventies. I mean, um. Uh, already there were movements to much more qualitative forms of practice and medicine had looked at narrative forms of practice far earlier than we did, and we've caught up I think very much so. Um, but a again, we still are, I mean we are historical and we still have that, those the, we're still emerging from the shadows of that.

What do you think the difficulty is for clinicians to. Again, put it in its proper perspective. We're not saying that the research isn't an important part of that, but in an important part of our practice. But it seems like there's, and, and I guess in my thoughts, it's, there's almost like this, it, it, it brings some uncertainty and, and lack of this security of like this research that kind of gives us the answers, right? And it gets us into some messy stuff, which is humans. Social worlds. They live in, um, psychological worlds. They, they obviously have that they uniquely bring to the. To the encounters. I'm wondering what your view is on why it's been so hard for us to move past that, that form of knowledge and really embracing where we recognize that there's a lot more knowledge in the room than what the evidence based components of that. And, and as you mentioned, patient values, um, you know, c clinician, you know, beliefs and all that stuff that very important as well. But wonder if you can kind of why, why the difficulty is of us moving.

Moving towards viewing knowledge in, in, in lots of different ways, how we tend to stick towards prioritized forms of knowledge. I think there, there could be a financial reason. So, um, if we treat the body as a machine, I think that that has, uh, we can divide up the body and that will be, uh, create not only social capital, but fiscal capital as well. I think there's an economic argument for it. I think there's a historical, uh, element where there are patients who recognize and have been socialized to believe that that is the right, right way. So that becomes a self-fulfilling circle. Um, also I think philosophically it's very, very difficult to pull yourself out of something that if you've signed up to, it's very difficult to now say, hold on a second, actually, there's way more to the body. And now I'm gonna give you a completely different philosophical background. So this is where the biopsychosocial model is. Good model. It is, is it is, it's such a challenge to integrate the different forms of the biopsychosocial model. Um, the reason I guess, is, is that if you, if we take, if we believe, let's say pain

mm-hmm.

The modern pain, uh, you know, care, um, podcast here, that if we, if we focus on pain, if we think that pain resides in the body, this is, this is pretty much drawing from Dave Nichols here, really. But if we believe that pain resides in the body. And the tissues, uh, it makes sense for us to adopt a biomedical perspective where we try to identify the nociceptive signals, the architecture around that. And I'm try, I will trichotomy this a little bit only to describe the challenge and then I'll see if we can integrate a little bit later. But if, if pain resides in the body, then I have to look to the tissues, I have to look at the systems, I have to look at those. Physiological processes, um, that expresses itself as well. In the way we practice. We'll focus on x-rays, blood tests, MRI scans'cause we want to identify the health of the tissues. Um, there may be some architecture of the future which might be able to help tell us how the nervous system processes this information, but we're not there yet. And there is a kind of philosophical idea that if we do have all of the knowledge, then we'll be able to find out and come at it from purely a physical perspective. But that expresses, its the way in which that expresses itself in practice means that our clinical times are going to be relatively short because you're gonna concentrate on those forms of knowledge. It also expresses itself in the environment that you're in. It doesn't make sense for you to be working in the biomedical domain and be, uh, and be working out in a community center. Because of our social history, it would make sense that we would have, or it, we are socialized to practice that kind of prac, uh, way in a very clean hygienic environment with a plinth and a, a desk with no decoration around. If we go into the psychological domain, we, obviously, the problem is again, philosophically, you know, how much do physiotherapists understand about consciousness? How much do we understand about, uh, Freudian psychoanalysis, uh, or lacanian psychoanalysis, or any of this kind of stuff? We, we are, we're so short on our understanding of psychology. And I guess people will say yes, but hold on a second. We'll have psychologists. We just work in a multidisciplinary way. I'm not about the practice coming together. They're very philosophically different. Pain that resides in the tissues versus pain that resides in consciousness or the brain or whatever, or psychology. They're very different Philosophical ideas and how they come together. It's not that easy. Appointments will be longer, the environment's gonna look different. And if we think that now the social determinants of health drive pain, and we believe that pain is, is, is a, an emergent, uh, aspect of, um, the social and historical circumstances that people have been brought up in. And the poverty and challenges that people have in the, the, the way that they've been treated by society, um, that's gonna look very, very different. They're very different philosophical starting points and integrating'em together. Yes, there's probably an element of all, but adopting one size fits all for those is very, very challenging. And I just think sometimes we have to be honest about where we're coming from and to say that. If we are bio-psychosocial, are we bio-psychosocial or are we quite happy to recognize that we cherry pick certain element elements, which are probably from our history? So for example, physiotherapists will be bio-psychosocial. They'll be predominantly biological. They'll have some element of cognitive behavioral element of psychology, and their sociology is really around kind of social economic understanding without actually any ability to do anything about it, you know, uh, although I'm not speaking for all physiotherapists that are physiotherapists and who you stand up for. People's rights who will be lobbying, who'll be, who are activists and working in that social domain. Absolutely. But I would say the general physiotherapist probably doesn't work in across those domains in, in perhaps the way that we could, or, you know, arguably, perhaps we should.

There are a lot of tensions that I think clinicians, uh, I know for me, you know, to consider outside of the body's machine meant all these letters I had accumulated after my name that were signifying, you know, you know, skill and expertise in, in finding that. Part of the machine, the body is a machine that I would be able to intervene with and, and fix. And obviously that was, you know, in certain situations that can be very helpful. Of course, in, in others, the ones that stick with you often are the ones that, where that doesn't work and that becomes a, a difficult thing. It, it brings me to the thought of what you've mentioned in your papers. And in discussions I've had with you, this thought of coherence, um, coherence is, is in as far as a coherent narrative around the knowledge that is brought into the room. One of the things we're trying to figure out, and I'm trying to figure out is how do we help clinicians not have this like bio psychosocial approach where there's actually some coherence in helping patients see the narrative. You nicely have pointed out that we have healthcare systems that have divided the body into chunks. And to me it's like the, the analogy I always use is we have a bunch of tree specialists who will look at one tree in a forest of a human that is and, and a forest beyond just human. It's the human, the, the, the environment they occupy the social world, the psychological world, like we've mentioned. Um, so I'm wondering if you'd speak to coherence and how you see that and what it means to you when it comes to, you know, clinical practice.

I guess this is where the bio, the biopsychosocial model. Can come into its own as an analytical tool. So it gives us an awareness of the multidi dimensionality of the situations that we encounter versus the practice. They're not necessarily the same thing, and in fact they're not. And I think even when I've seen multidisciplinary teams, uh, and they have their own specialist areas of knowledge, they still practice in siloed ways. Nothing doesn't. So, so, so there's a coherence of ANA analysis. Which I think is one thing, and there's a incoherence or coherence of practice and, and they're not necessarily the same thing. So I think we've made strides, um, in our analysis of, of understanding how to put a biopsychosocial lens on people. I do genuinely think we've made strides. However, only in 2022 you've got, um, um, oh gosh, I'm not gonna say her name correctly, uh, Karima. Um, me mosquito a mosquito. I'm gonna get it wrong. I'm so sorry. Karina. Um, uh, and colleagues in, in Australia, um, who, who say that we can't, we don't practice the bio psychosocial model in that way. So we, so I think there's a coherence. And how do we, um, I think we need a pH I think we need a philosophy of practice that we are gonna stand by. That's the first thing. So Asaf, who I think you've had on the podcast, he is a staunch advocate for the no apparatus. He's a, in my mind, and I'm, he, he, I'm sure he will come back to us if, if I've, um, misquoted or misrepresented him is a physicalist in that sense. Right. So his philosophical position as I understand it, right, is that. Doesn't matter which an analytical aspect you're gonna come from, it's psychological, social, or whatever. It will manifest in one way, shape or another in terms of the amplitude, frequency and engagement of the nociceptive apparatus. And therefore, if we can interact with that nociceptive apparatus, doesn't matter if you use psychology, sociology, or biological, although he has I think, a biological lens, you are going to have some effect on the ne epi operator. I think that's very coherent. And you know, I don't necessarily have to agree with it, but I think it's a, it's a, it's a, it's a philosophically coherent argument. Um, and I think that, that, uh, when we speak to coherence, I think it's gotta start off from some kind of theoretical. Backing that we are happy to stand behind may not necessarily be true, and we have to be open to criticism and be able to, uh, flex. So have strong beliefs, but don't hold them too tightly because as we know, things change. Uh, and if we're talking about knowledge, knowledge. Unfolds emerges and we have to move with it. It's a dynamic thing. It is not static. And we, as physical therapists, I think it's interesting, we tend to like to hold onto things. There's a kind of certain irony about physical therapy not wanting to move, even though we are movement therapists or movement, you know, oriented clinicians. So, um. So anyway, yeah. So I think that first of all, we need to have kind of philosophical coherence, philosophical or theoretical, uh, standpoint and recognize the strengths and limitations of those. So for me at the moment, my kind of, I have a pluralistic, uh, view of knowledge. In other words, I'm not gonna just take one position. Um, and. I think I need to have that flexibility so that when I practice, I can practice in a way that suits that situation that I'm encountering. So if a patient comes from a, from a particular, um, or is open to a particular theoretical perspective, I will follow the patient. I will follow the patient's lead if they have a particular biological. Biomedical oriented perspective. I'll follow them slightly on that journey, but only so much as to say, is this working? And I think people like Peter Sullivan, cognitive functional therapy, they do this really well. They follow the patient on this bio biomedical journey, and they show them that it's. Incoherent to follow that model. And so they open up a whole host of possibilities for that person to think of things otherwise, and I think that's what good, good physical therapists do. You know, they open up the possibilities for something new. We don't just follow protocols, we don't just follow algorithms. And that's why I think an epistemic plurality being open to different forms of knowledge is the right is for me a better way to go because it means I can follow the patient. Where they're going. I get a sense of where their background, their context is. I'll follow them and then I'll open up, is this working? If it's working, great, let's do it. How can I help you do that? If it's not working, how can we look at things otherwise? And, and I'm, and in my PhD work at the moment, I'm kind of really opening up that in a kind of very radical way. This comes from practice. It's, I think, comes at for what I think is one of the intensive aspects of physical therapy, which is creating, uh, opportunities for expansion, for, for openness and, and, uh, and change. And that's what I think is interesting about, about being a physiotherapist.

You mentioned it's hard for us to move on and this is a safe space, so, and, and, and we, we, I will field any blowback if we get any I'm, I'm kidding. Of course. But where, where do you see us struggling to move on? Like I, I've talked about things. I have my ideas of where I think we struggle to move on, um, as physios.'cause I think we do have a ripe opportunity in front of us if we can. I suspend our, our ego and maybe our clinic and, and,'cause I think it's sometimes hard for physical therapist physiotherapists to, you know, and you mentioned good ones do this. But I think sometimes there's this, we want to take the lead, you know, it's, it's the, you know, more paternalistic view and it, it comes from maybe, you know. Biomedical traditions where the physician sat at that kind of hierarchical level with people. But I'm, I'm wondering if you could speak to what you think are kind of, some of the things, and we don't have to obviously get too detailed unless you feel like there's things out there, but like what do you think are the things that we really would help us if we could just move on from, like, what are the things that you feel like are, are, you've mentioned some of it already of course, but I'm wondering if you could speak to what you feel holds us back the most.

I think some of the thing is just some of the implicit things that we take for granted. So, um, the idea of subjective and objective being two separate phenomena taken in a, in a, in a, in a clinical interview, for example, if we call it a clinical interview or a patient encounter, whatever word we feel most comfortable with. Um, so even, even so in the uk we write soap notes, subjective, objective analysis and plan. So straight away we're dividing the patient up. Into subjective. What's subjective? It's what the patient says is, uh. The case. So already there is no such thing as the clinician's subjectivity. The subjective nature of the encounter is purely the patient's subjectivity. Right. And then when we talk about objective, what's objective? Ah, it's what the therapist's perspective is.'cause we are that objective. Oh. Yeah, we are, we are really objective. You know, when we look at somebody move that's really objective. When we, uh, even when we use instruments like goniometry, we're not particularly objective. We know that when we do passive assessments, we are not objective yet. That's how we write things down. So the idea of separating even in our soap notes, right? Subjective, is the patient objective is the therapist. I mean, come on, it's a nonsense. So I think there's some real basic things that we can change and, and it, and that is a philosophical bias. That is a, something of which we, and that has come from a good place, don't get me wrong. It's come from, as you say, a paternalistic, you know, biomedical. You know, histor history, it's historical. There's no reason why we can't change it. We could choose lots of different ways to encounter patients. Um, so I think that's, that's one thing I think that would, anything that changes the power relation between those that we serve and ourselves. Is gonna be a good thing. I think an awareness of those correlation differences is gonna be important. And, and, and being aware of our own biases, right? When we do that, and I'm not just talking about cognitive biases, I'm talking about all biases, plural. Um, so then I think there's, there's the question of what, what do we tend to hold onto? Um, I think. What do we think is important? What, what? I think here's, here's an interesting idea. We talk about value quite a bit. So what's the value proposition here? Um, is that fiscal value? Is that outcome? Is it, um, patients, um, experience and I think, I think there is, there is something here about what. Is health. And I think that there is something, and this is gonna sound a bit abstract, but, but I actually think if we were to just decenter ourselves from the healthcare context, I think that could open up a whole different host of how physical therapists could be, uh, or could become. That doesn't mean that everyone has to be this way. I'm just saying that it can open up physical therapy for the good of health in its broadest nature. And that's where, if we think of those things. Things like environmental physiotherapy such as those that Philip Mar heads up at the environmental physiotherapy. Um, uh, the EPA, um, he, you know, it, it, it, it makes us think of a. A whole host of different ways. If we can practice, even if we use, use a model like the bio-psychosocial model, what stops us working in the social context? W working in, uh, social environments, communities, homeless areas. Now we do do that sometimes, and there are obviously there's prison, uh, physios and things like that. Um, but how, how about we actually start to. Embody an environmental and social standpoint and be, uh, a part of a therapeutic, um, uh. Facilitator for wants of a better description, um, in its broadest sense. And I think at the moment we tend to think of in musculoskeletal physiotherapy health in a very, very narrow way. It's usually pain metrics, which I, which is understandable. I get that. Uh, it doesn't help necessarily with other aspects of health, but it's certainly an important element and I don't want to diminish that. Um, but it is a fairly narrow way, um, power strength. Balance those physical features. Um, so I think how, how do we break away from some of those kinds of practices? There's also the ne neo, the, the kind of political way in which physiotherapy has evolved over the years. Um, so again, I'm speaking to Dave Nichols type of work here and others who talk about neoliberal forms of practices of how self-management could be seen as a way in which we, uh, give patients ownership. We empower them, but actually diminish, um, our support for the patient. In that way, or it could be misconstrued in that way. So just a few things that I think we can try to let go of some of our historical things that anchor as inter stasis.

We talked about this at lunch, uh, which all you are here on of course. But the, I I thought it was fascinating'cause I, I didn't even know this study existed. The back cafe. You gotta tell people about the back cafe.'cause it, it's a great example of taking our practice outside of this, this traditional. Sterile environment that you talked about earlier where there's the PTH and things and you bring it out into the world in the context where these people function. Right. Because I, as I mentioned to you, I, it's, to me, I see like we, we get so excited about change in our four walls within session change, which again, not saying it's not, can't be helpful, but what about within life change? Right? And, and I, I just think as, as you've, as I've talked to Philip and you and others. It, it, it makes so much sense for us to start being creative and getting outside our walls. Just because we've had to identify with a biomedical approach doesn't mean we have to be beholden to it. And maybe it doesn't mean we're leaving it either. Like we can still interact and interdisciplinary engage with maybe some of our more biomedically driven, uh, prof professions and, and fellow, uh, healthcare professionals. But I'd love if you could unpack that a little bit as far as like the, the, the back cafe, which was, which, which was, uh, again, I think a great example of, and we're gonna link it in the show notes. I, I gotta find the study. I'm hope Matt's gonna hook me up with it. I'm sure. But tell, tell people about it.

Yeah. I think it's quite an old paper. So I think it, it's a Scandinavian, it was done by some Scandinavian researchers, um, and it was, I think published in 2010. I will get it, that may be wrong year. But essentially, um, what they did is they did a randomized control trial study where they, um, compared. Um, a group of people following back surgery and, uh, the two interventions were a back rehabilitation circuit based class for about 12 weeks versus, um, a back cafe. Um, so the nature of the. Uh, the physical rehabilitation is much more of a traditional based, you know, circuit based program. Gradual, progressively increased loading, uh, as you would expect over a circuit based program. And this has done the world over. And then they compared it to a back cafe where people, uh, turned up to a cafe and there was a phy, uh, uh, a, a senior physiotherapist who basically spoke to them all. Uh, asked how people were getting on, encouraged dialogue amongst the group. Uh, had some hot topics to discuss about postoperative care. Uh, opened up the opportunity for people to catch him either on a group basis or a one-to-one basis, and it was a social intervention essentially. The, the, the, the, the, The group that had the best outcomes was the social cafe. It was the back cafe. It was the back cafe. And there's something to be said about that. It, it, it doesn't eliminate physiotherapists at all, and it doesn't close off the idea that, uh. You know, back rehabilitation classes aren't useful'cause both, both groups improved. But the ones that had, uh, the, the group that had the statistically significant, um, better outcome was the back cafe. And, um, I. There's a part of me that thinks that if that opens up a whole host, and I haven't seen many studies, uh, incorporating that viewpoint. And maybe the viewers, uh, and the listeners may, may have more to that, but I don't think there's much around that. And I think, I think we probably need to step into that domain in the research and practice side of things where we can offer our, uh, uh, our expertise as physical therapists. But in a social context and provide a, in quotes social intervention, uh, and maybe multi-agency. We can bring neighborhoods, communities together, um, which are meaningful for that patient cohort and work in a way that is far more dynamic. Um, and of course if people need, uh. Perhaps a little bit more one-to-one support. Of course they can have that. Uh, and maybe if we were to go into much more of a supervised exercise program that's on the table. But, uh, there's a part of me that thinks that maybe we should start with a social first.

That's part one with Matt Low. We didn't get into AI and where physiotherapy goes from here, that's coming in part two and it's worth the wait. If today pushed on something for you, the kind of thing where you're questioning how you've been waiting knowledge in the room, that's exactly what we worked through inside Modern Pain Pro. Our Community Link is in the show notes. Would love to see you. Join us. See you all in part two.

This has been another episode of The Modern Pain Podcast with Dr. Mark Kargela. Join us next time as we continue our journey to help change the story around pain. For more information on the show, visit modern pain care.com. This podcast is for educational and informational purposes only. It is not a substitute for medical advice or treatment. Please consult a licensed professional for your specific medical needs, changing the story around pain. This is the Modern Pain Podcast.