Evidence-Based Practices Must Evolve Over Time

It’s always a little embarrassing to look at old photos and see how you used to dress. Those baggy jeans and the bowl cut seemed like a great idea at the time. Perhaps it was reasonable since all the other kids in grade 5 were doing it, and it was somewhat ‘in style.’ Styles change. Our opinions can change, as can our knowledge. This also happens in the world of musculoskeletal medicine and rehabilitation.

As the Literature Changes, So Might Our Recommendations

This weekend Dr. McDowall and I were at a course that challenged many long-held beliefs in the field of musculoskeletal rehabilitation. It reminded us of some of the ideas we had in the past that we don’t recommend anymore. For example, I’ve written numerous blogs on our website, promoting an optimal scapular movement pattern or a proper movement pattern for the lumbar spine. I’m not sure I would entirely agree with this anymore, although the advice probably still helped a lot of people. It’s very common for patients to come to our clinic with an opinion of their diagnosis or their management strategy based on misinformation from the internet (or at least information that lacks a sound scientific basis). I suppose I can be comforted that our advice and our blog posts had some reasonable scientific evidence at the time. What I’m acknowledging here is that the literature changes, and so might our recommendations. We’ve been writing blogs on this website since 2008. Would I completely agree with everything we posted since that time?

A specific example of this might be an ACL prevention program that Dr. McDowall and I presented to a youth soccer club over ten years ago. We spoke to a room full of coaches and had a number of teams come to our facility and go through a movement screen and some orthopaedic tests. We looked for faulty movement patterns that were described in the literature as predictors for future ACL injury. I cannot recall if we recommended that any of the players drastically change the way they jump and land, but that was the focus of the program and the literature to support it. Would I agree with all those recommendations today? The answer is that I’m not sure, but I might not be as adamant as I probably was at the time. The science isn’t a slam dunk.

Another example would be scapular dyskinesis. In the past, I would spend a lot of time carefully examining patients’ scapulae (shoulder blades) for faulty movement patterns. I would scrutinize the medial border of the scapula if it had the audacity to deviate from the thoracic wall or be different from the other side. I would prescribe exercises that were intended to change this movement pattern, with, of course, ‘decent’ evidence and good intention supporting the advice. Today, I likely wouldn’t worry about slight asymmetries. Perhaps what is interesting is that I might still recommend the same exercises, but my rationale would be different!

A Good Time for Reflection and Possible Re-evaluation

As outlined in previous blogs, evidence-informed practice involves consideration of the current scientific evidence, a practitioner’s clinical experience as well as a patient’s viewpoint. All of these things can change with time. Perhaps over the last ten years, not only has the evidence changed, but so have my experiences with different injuries and the strategies that have worked for my patients. Sometimes a recommendation may have been reasonable in the past, but variables have now changed, and the opinion might be different now. I always love this time of year. It fosters reflection as well as providing a fresh start in the New Year. If you have an injury that hasn’t improved or if there was a recommendation made to you in the past that you aren’t sure about now, perhaps it’s a good time to re-evaluate. On a personal note, I would invite any of my patients to reach out to me if they aren’t sure whether the advice I gave them many years ago still applies or if a previous blog entry still makes sense. Perhaps the literature has changed. Perhaps my experience has compelled me to think differently. Perhaps I would still make the same recommendation, but maybe my reasoning and the science behind the advice has changed!

Happy Holidays!


Dr. Kevin McIntyre

Chiropractor / Clinic Director