Before I get to the post: I am on my way to the HOD/NEXT Conference. I would love to meet some new forward thinking physical therapist, so send me a tweet if you are in Charlotte.
Change is not an easy thing for most people. We find comfort in the familiar and it is difficult to modify how we think, how we act and what we believe. This can be useful, especially when those thoughts, actions and beliefs are based on good evidence and sound logic. However, even when confronted with good reasons to change, there is often hesitation and resistance.
Healthcare professionals are not immune to this attraction of the familiar. We often use theoretical models and treatments because we have a long history with them, not because they are the most defensible. On the flip side of this resistance to change is the interesting phenomenon of the bandwagon effect. This occurs when we more readily accept something as true based on the number of people who believe it, rather than the merits of the concept. For any number of reasons (good salesmanship, seemly logical rationale, simplicity of the concept, complexity of the concept, financial etc..) certain treatments or theoretical constructs circumvent our resistance to change and go viral. This often does not occur in a measured, well reasoned way, which takes into account the potential positive and negative aspects of the issue. Instead, the professional pendulum swings and everyone needs to think a new way or perform a new treatment technique or they will be left behind in the dust. I have seen this happen (and joined in a few times myself) numerous times in the physical therapy community. Common examples of this mass flocking to a particular concept (in the absence of evidence to justify the fervor of the conversion) are spinal stabilization, augmented soft tissue massage, movement screening, myofascial release, dry needling, thrust manipulation, etc….
Another potential example of the bandwagon effect in the physical therapy world is the switch from tendonitis to tendonosis. Several years ago tendon disorders were considered to be a disorder cause by inflammation. After a few studies, the tide changed and chronic tendon problems (relatively) quickly became seen as non-inflammatory. This resulted in a movement away from interventions focused on reducing inflammation and towards other interventions such as aggressive augmented soft tissue massage, blood product injections and eccentric training.
A relatively recent (about 1 year old) article by Rees et al examines some of the evidence behind this move away from the inflammation model of chronic tendon conditions. In this article they do not suggest we go back to the 1990’s where inflammation was king, but it suggests that we take a more measured, well thought out view of the topic.
“to regard all chronic tendinopathy as entirely noninflammatory is an oversimplification to the point of being misleading.”
The article starts with a brief explanation of the history of behind the movement away from inflammation. It then goes on to challenge this widespread change in philosophy by first addressing the notion that inflammation is not present and then reviewing the effects of anti-inflammatory interventions. Knowing the challenges of designing a well controlled intervention study, I found the information questioning the notion that inflammation is absent the most compelling. They cite studies, using newer more accurate techniques, which have found direct evidence of inflammation in humans and animals with both acute and chronic tendonopathy. These studies found evidence of macrophages, T and B lymphocytes, interleukins, cyclo-oygenase, TGF-B, substance P and others. There is also indirect evidence of the presence of inflammation such as increased number and larger tenocytes and neovascularization.
In light of these findings, is it possible that our often strong views on tendonosis are an example of the bandwagon effect? Should we re-assess our beliefs about itis and osis and take a more measured, nuanced approach?
This is a link to the full text of the article and I recommend you take a look at it.