This is the second in a series of posts about Diane Lee’s Integrated Systems Model (ISM), which is a big part of how I work, and which helps me to work out not just which bit hurts, but where your problem is coming from. Last week I wrote about how I came to find the ISM in the first place; this week it’s time to talk about evidence-based practice.
One of the things that some physiotherapists criticise about the ISM is that there is no “evidence” that it works. This is definitely an issue to address, because “evidence-based practice” is a huge buzzword within the medical community.
What is evidence based practice?
So – what is “evidence-based practice”? Professor David Sackett and his team have been working on a definition for years, but essentially their criteria are:
- Patient values and expectations
- Individual clinical expertise
- Best external evidence
Practice can be considered truly evidence-based when all three conditions are met, though there is merit in each individual condition.
Values and expectations
Incorporating patients’ values and expectations is vital. Many of my patients do come in complaining of pain; but not all of them. Some people come to see me because they feel “wonky” or because there’s something that they can’t do – it could be that they can’t touch their toes, or that there’s something in their body that’s stopping them from being able to dance, or so specific yoga poses, or hit a tennis serve, in the way they feel they should be able to. Just helping someone to get out of pain doesn’t mean their body will work in the way that they want or need it to, or in the way that it worked before they felt the pain.
I don’t only need to know what’s wrong with them in order to be able to help them. I need to know what matters to them, and what they want to achieve. If they want to be able to do a handstand, then teaching them to run better is of limited usefulness! I also need to know what my patients believe about their bodies. If they are convinced that their problem is coming from their knee, and I think it’s coming from their foot, then we have to discuss and test – if I just ride roughshod over their beliefs then I will lose their trust, and even if I am 100% right clinically, I will fail my patient.
Individual clinical expertise
Individual clinical expertise is something that gets dramatically under-recognised, in my opinion (though I would say that – I’ve been a physio for nearly 20 years, and while that’s not as long as Diane who has been a physio for over 40 years, I feel that my experience ought to count for something!) Clinical expertise is defined as a combination of skill acquisition (how to do the treatment tools that are in your toolbox) and clinical reasoning (when to use which tool) – so it’s very much not just about how long you’ve been doing the job, but practice combined with reflection and teaching definitely helps!
Best external evidence
Combining this with judicious use of the best published external evidence is also important – but you do have to be careful about which research you are using and following. It’s possible for papers with apparently-identical methodologies to contradict each other, and it’s only by reading the small print very carefully that you realise that one research team was following football players and another office workers, for example – and different groups of people will respond differently to different types of treatment. Professor Sackett’s opinion is that “external research can inform, but never replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all, and if so, how it should be integrated into a clinical decision”.
My issue with randomised controlled trials (which are often considered one of the strongest forms of evidence) is that each one begins with “we took a group of homogenous subjects” and I do not believe people, their treatment or their results can be homogenised. I have never seen a single patient who fits perfectly into the inclusion criteria of any RCT that I have ever read; I have never seen a single patient who responded exactly like the mean value of the subjects of the RCT; and I have never seen two physiotherapists treat patients in exactly the same way. So because of these methodological flaws, I am not convinced that published research is the most important thing on which to base my clinical decisions. Despite this, some clinicians only look at the third condition, and say that therapists who don’t base their treatment on the results of randomised controlled trials are performing poorly; some even go so far as to say that we should not offer any sort of treatment until the evidence is present and published to support it. (If they are right, then there are all sorts of treatments which are effective in practice but which we could not use!)
The problem with classification systems
Talking of homogenising patients, the ISM actually arose from Diane and LJ’s attempt to find a new classification system for their patients.
Within the world of medicine, many excellent practitioners and researchers have suggested ways to classify patients and their injuries – effectively a form of pattern recognition, which enables therapists to “short-cut” their clinical decision making. This is how “syndromes” (collections of symptoms) are defined, and it leads to various schools of thought when it comes to treatment. For example, when we are trying to classify back pain, we have various options including:
- Pathoanatomical models (including, for example, Sarah Key’s model)
- McKenzie’s mechanical model
- Sahrmann’s movement system impairment model
- O’Sullivan mechanism based model
- Delitto treatment based model
The problem is that all of these classification systems begin with pain, and none of them meets the needs of every patient you see. Diane and LJ tried each of these models, but ended up finding patients every week who didn’t “fit”. They then started by trying to produce their own classification system, but again kept finding outliers. Eventually, they decided that trying to put patients into boxes actually didn’t work, and realised that it was more effective to work out a way to treat each patient as an individual. And thus – over many years – the Integrated Systems Model was developed, more as a clinical reasoning pathway than as a way to recognise patterns.
Over the next few weeks, I’m going to continue writing about exactly how I assess and treat my patients using the Integrated Systems Model, including case studies of patients whose symptoms weren’t originating from the areas that hurt. However, if this already resonates with you, and you’d like to be assessed and treated as an individual rather than as a set of symptoms, please call my team on 0207 175 0150 and book a 90-minute physiotherapy assessment. I’m looking forward to getting to know you!