Emotional-based practice

In 1999, David Isaacs and Dominic Fitzgerald offered up seven alternatives to evidence-based practice when faced with a situation where no evidence exists on the topic at hand.1 Their jocular suggestions of (1) eminence-based medicine; (2) vehemence-based medicine; (3) eloquence-based medicine; (4) providence-based medicine; (5) diffidence-based medicine; (6) nervousness-based medicine; and (7) confidence-based medicine reflect the arrogance, nihilism, or lack of confidence displayed during decision making by physicians, nurses, and surgeons. Although meant to be funny, the editorial is decisively accurate and despite being over 10 years old it is not dated in context. Truly, these are the unsightly alternatives to evidence-based practice. I do think one alternative to evidence-based practice is conspicuously absent from this list. This alternative, which I call emotional-based practice, differs from Isaacs and Fitzgerald’s1 suggestions because emotional-based practice is utilized when evidence exists to refute the use of a specific test or intervention (not during a lack of evidence). In other words, the clinician has elected to use the test or intervention despite evidence to the contrary. They elect to do so because they are personally and emotionally attached to the test or intervention. But before we condemn emotional-based practice, let’s discuss how research is disseminated in clinical practice; because quite frankly, this is no easy task. Rogers’2 adoption/innovation curve (Fig. 1), which was first proposed in the late 1950s, has frequently been used as a model for dissemination of innovation or research. The innovation curve suggests that approximately 16% of those (a group called ‘laggards’ by Rogers) involved in the dedicated field (for example, manual therapy) will either be significantly delayed in their adoption of information or will never adopt the information. I think that the number is probably higher. Around 34% falls in the ‘late majority’ group, a group that has been described as a ‘skeptical’ population by others.3 A certain degree of skepticism in healthcare is constructive, as it delays the implementation of a poorly vetted clinical treatment. However, when evidence exists to refute the use of a specific test or intervention, skepticism loses its value. Figure 1 Innovation curve for dissemination of research. In defense of our colleagues who continue to use specific tests or interventions when evidence exists to refute the use, it is worth mentioning that up to 30 000 papers on biomedical literature are published yearly.4 Furthermore, folklore, myth, and information handed down over the generations have duped a number of healthcare professions and the lay public as a whole. For example, myths such as (1) people should drink eight glasses of water in a day to maintain good health; (2) we only use 10% of our brains during normal activities; (3) hair and fingernails continue to grow after death; and (4) reading in dim light ruins your eyesight are accepted as truisms, even though there is no evidence to support these claims.5 People still call chronic Achilles pain, lateral epicondylitis, and rotator cuff injuries ‘tendonitis’, despite that we have known for years that there is generally no inflammatory aspect to the processes.6 It is easy to see why there is the mistake in advocating certain tests or treatment, if we have misinformation. However, when one knows that evidence exists to refute the use of a specific test or intervention, yet he/she elects to use these procedures anyway; that is, emotional-based practice. I would argue that this is the most significant problem that delays our pursuit of evidence in support of manual therapy. I have encountered emotional-based practice a number of times over my 20 years of a clinician but have noticed the feverishness of this more so in the last 3–5 years as evidence has grown and has become more prominent in clinical practice. Specifically, I have witnessed an emotional attachment to particular orthopedic manual therapy procedures (‘fix all’ procedures), orthopedic special tests, screening tests, and diagnoses. Let’s consider the following clinical examples: (1) the use of the straight leg raise (SLR) as confirmatory diagnostic test for a disc herniation; (2) allowing a clinical prediction rule (CPR) to trump clinical reasoning that refutes proper use; and (3) the continued insistence that palpation tests of the sacroiliac joint are diagnostic for sacroiliac joint syndrome.