How blogging about physiotherapy research can get you fired

This is a reblog from Haraldur B. Sigurðsson’ Blog

We are working in this relatively young and rapidly developing profession. We should never halt and be satisfied with our skills. Question yourself and your practice! Evolution beat the dinosaurs – don’t be a dinosaur 😉

“Recently, a blog post I wrote about limitations of spinal manipulation got me fired!

Haraldur Portrait

Haraldur B. Sigurðsson

Somehow that doesn’t surprise me, maybe that’s just what happens when you rattle some dinosaur cages. A dinosaur in physiotherapy is someone who is stuck in the past, and refuses to update his/her views with new evidence unless it feeds their confirmation bias (1). It’s obviously not a technical term, but a valid description that I am by no means the first one to blog about (2). It’s also not a blanket description of everyone that graduated before me. It’s not the age that defines the dinosaur, but rather the attitude. There’s plenty of physios with many years of experience that still remain open to new ideas and evolve their practice to reflect these ideas.

Dinosaurs and their followers are very prevalent today, even among the young folk who work with and are influenced by the older ones. It’s only in recent years that evidence based physiotherapy is flourishing, facilitated by the explosion of research (3) coupled with social media that allows the open discussion, criticism, and dissemination of information by physiotherapists (4).

And, naturally, the dinosaurs are pissed. Not only has almost every therapy they have been providing failed the test, but the whole paradigm of why these treatments should work has failed. Dinosaurs are too deeply committed to these outdated ways of thinking to objectively evaluate the science, too married to old ideas to divorce them. To them, decades of consistent research can be brushed off with “you can feel it working”, or “It’s been working for years!”, or even the abysmally short-sighted “I have a waiting list so I must be doing something right”. They are in an endless loop of using temporary analgesic effects to justify unnecessary or even harmful treatments, confusing immediate patient satisfaction with good clinical outcomes and consciously forcing patients in dependency instead of promoting self-efficacy.

So when I challenged the dinosaur viewpoint by pointing out that there are important limitations to spinal manipulation, I got fired.

Icelandic physiotherapy is undergoing a silent crisis, and in my opinion dinosaurs are causing it. The average out-patient physio in Iceland sees ~5,5 patients per day (5), which is less than a full time job. Some of the more popular ones see 18+ patients per day, which means that at the lower end are physios who hardly see any patients at all.

Seeing 18 individual patients per day can’t be considered ethical practice. That means working 9 hours straight, without a break, every day. Making decisions and staying focused becomes difficult (6). It gets more and more tempting to just do the easiest thing, and that often includes providing passive analgesic therapies. Using active treatments and engaging the patients in a therapeutic union takes presence of mind and concentration. I would sure not like being patient number 18.

Discussing treatment options and prognoses – real prognoses, not a unicorn story – may end up with a patient deciding not to attempt an intervention. And that’s ok, people have a right to accept or decline any medical treatment plan. It is our job as physiotherapists to provide patients with the best possible information regarding their condition and work with them to tailor a treatment plan. This may include various therapies if indicated and the patient chooses to use them after discussing it with the physio. But sometimes, this includes one of the hardest decisions a physio makes: recommending no intervention at all.

Other times this may include something unpopular, such as recommending that a patient skips a competition or a planned trip. In that situation, it’s our job to provide the patient with information regarding possible risks associated with participation, but the patient usually makes the final decisions, after all it’s their risk. If the therapist is greed-driven, working from a business model of more sessions per patient = better, these are surely worthless strategies. In that case, it’s much better to tell the patient „we’ll do everything in our power to make that trip!“ and proceed to throw every therapy under the sun at the patient and hope for the best.

Dinosaurs have indeed become good at milking as many treatment sessions as possible out of every single patient that walks through their door. They take their money by spending countless sessions fixing imaginary blocked sacroiliac joints, softening up tight muscles, and telling stories about remarkable single-session quick fixes.

The same udder-squeezing skill-set results in increasing numbers of patients who realize they spent considerable time and money for little benefit. This in turn creates people who are skeptical about physiotherapy, and will just stop booking sessions. It’s a vicious cycle of over-treating causing decreasing numbers of sessions, resulting in increased over-treating.

Evidence based physiotherapy is – compared to the bloated dinosaur therapy – streamlined, resource-efficient and requires much fewer treatment sessions on average. It’s a scalpel next to a chainsaw. It’s a breath of fresh air next to a garbage dump. Even the popular dinosaurs can smell the change coming, and they are stressed enough over it to fire people like me for making the patient better informed.

Even patients that receive a fake therapy, literally a machine that is turned off, will still improve with treatments (7). This means that every physio will get apparently decent outcomes by simply being equal to the passage of time and a machined turned off. The goal is to provide the patient with information about their condition and the efficacy of possible treatments. Every intervention attempted should have a good chance of performing better than time, and to that end it’s so important to use the research evidence to weed out the useless therapies and set reasonable treatment goals. If no treatment is indicated – the patient will receive information regarding his condition, but no voodoo tricks.

The trend is to increasingly emphasize evidence-based physiotherapy in physiotherapy education. It’s also increasingly emphasized that the knowledge gap between science and the public should be bridged by communicating findings to the public. I got fired for just that, discussing information and evidence – evidence the dinosaurs obviously want to sweep under the rug so they can remain complacent and their clients blissfully ignorant. I believe more physios need to openly support evidence-based physiotherapy and speak up against these outdated methods and together we just might be the meteor that saves physiotherapy.”Dino

ENPHE Thesis Award Winner!

The ENPHE Conference took place from September 15th - 17th in Graz, Austria. Each year, a price is awarded to the best Physiotherapy Bachelor's thesis. Last year a thesis from the European School of Physiotherapy won 1st price already.
As you might have seen on our social media outlets , we were one of the Top 5 shortlisted candidates for this year's thesis award.
This Friday, we received great news from the committee: WE WON 1st PLACE! 🙂

We were pleasantly surprised with our official certificate and prize money during our tutoring seminar we give to first year students on Tuesdays!

This makes us extremely happy as it is a great reward for the efforts we put into the thesis and product (e-learning environment).
If you want to know more about it, watch the presentation below. You can download the thesis paper by clicking here


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Clinical Bias

We have just finished our first weekend of our part-time Master studies and we had to read a nice article in preparation for a lecture. It sparked great thoughts and got us thinking. Read more below.


Look at the grid:


You’re probably seeing black dots in the matrix above, right? Even though they’re not there you still see them – at least you think so, or better, your brain thinks they’re there.

You might run into the same problem when evaluating a patient. Your decisions should be of the best possible quality as they have an effect on your patient’s health. A shown by the grid above, there are similar pitfalls affecting your clinical decision making: cognitive biases. Your brain plays a trick on you making you prone to jump to conclusions using heuristics instead of systematic decision making.

There are several possible pitfalls we may encounter in our practice or clinical decision making:

  1. The representativeness heuristic
    It describes the assumption that something that seems similar to other things in a certain category is itself a member of that category.
    Participants were presented with descriptions of people who came from a fictitious group of 30 engineers and 70 lawyers. They were then asked to rate the probability that the person described was an engineer. Keeping in mind that only 30% were engineers, the participants’ judgement were much more affected by the extent to which the description matched the stereotype of an engineer (e.g. “Steve is conservative and careful”) than by the base rate (30% were engineers). This shows that representativeness had a greater effect on judgments than did knowledge of the probabilities. (Kahneman & Tversky)
    The same heuristic has been shown in nursing. Nurses were given two fictitious scenarios of patients with symptoms suggestive of either a heart attack or a stroke and asked to provide a diagnosis. The heart attack scenario sometimes included the additional information that the patient had recently been dismissed from his job, and the stroke scenario sometimes included the information that the patient’s breath smelt of alcohol. The additional information had a highly significant effect on the diagnosis and made it less likely—consistent with the representativeness heuristic—that the nurses would attribute the symptoms to a serious physical cause. The effect of the additional information was similar for both qualified and student nurses, suggesting that training had little effect on the extent to which heuristics influenced diagnostic decisions. (Klein, 2005)
  2. The availability heuristic
    Placing particular weight on examples of things that come to mind easily, as they are easily rememberred or were recently frequently encountered.
    You just read a great editorial on the incidence of SI Joint dysfunction in LBP. Suddenly, a high number of LBP patients you see SURELY MUST HAVE SI joint problems 😉 It seems obvious to you in the heat of the moment as things that come to mind easily are likely to be common but chances are that your brain is misleading you. In order to avoid this ask yourself whether information is truly relevant, rather than simply easily available.
  3. Overconfidence
    This is a tricky one. We all think we are masters of our trade, don’t we 😉 . But to use our knowledge effectively, we have to know the limitations. It is crucial that we identify gaps in our knowledge which in turn lead to suboptimal treatment. Overconfidence can also result in hasty decision making in clinical diagnosis. Therefore it is key to be aware of the limits of our knowledge and to keep it up to date. Make a habit of asking colleagues for opinions and do your research to stay up to date.
  4. The confirmatory bias
    It’s the tendency to look for information that confirms your pre-existing expectations. On the other end, information that contradicts the pre-existing expecation may be disregarded.
    Asking questions, or worse to stop asking questions, during patient history taking when information obtained fits with your early hypothesis. To avoid confirmatory bias, rather ask questions that may contradict or discard you early hypothesis and don’t regard that information as irrelevant.
  5. The illusory correlation
    This one is especially prevalent in statistical analysis. It’s the tendency to perceive two events as causally related when the connection between them is, at most, coincidental or even non existent. Surely there is overlap with confirmatory bias when an outcome fits pre-existing ideas. A popular example is the claim that homeopathy works when a patient improves after being administered a homeopathic drug even though there is no sound evidence. Homeopaths will likely remember occasions when a patient improved after treatment – illusionary correlation.
    Don’t fall for these incorrect beliefs which may in turn lead to suboptimal practice.


It surely got us thinking and reinforced us to stay alert for biases and have an open mind each and every time we see a patient.





Injury Prevention in the Overhead Athlete

Two weeks ago, we have started a “shoulder assessment” series on our Facbebook Page. Our last blog dealt with the comparison of surgical and conservative management of rotator cuff tears.
In this blog post we would like to present to you a review and protocol done by friends of us titled “RISK FACTORS FOR SHOULDER INJURIES IN OVERHEAD ATHLETES”.

The review’s objective was to identify and to examine the evidence for shoulder injury risk factors in overhead athletes and transfer the findings into a prevention exercise program targeting these risk factors.

We believe they have done a good job in accumulating valuable evidence and translating the finding into an appealing exercise program

You can find the poster and program below! Let us know if you like these shares!


Poster Download