Critical thinking is not being critical, and just being critical is not critical thinking.
I have decided to write this piece on the subject of critical thinking mainly so I can reflect on what it is and ensure that I am doing this and not just being a 'critical arse' which I have been accused of on more than one occasion when I dare make comments about treatments, methods or explanations used by some in the therapy world!
Critical thinking is something we should all be doing daily, hourly, in every walk of life, from deciding if the new dishwasher you're going to buy is the best on the market, to wondering if really a pot of face cream can get rid of your wrinkles.
However, in my opinion critical thinking should be used within the therapy industry a lot more than it currently is and it shouldn't be seen as threatening or negative, rather it should be seen as positive and challenging, enabling us to expand our own thinking and understanding allowing us to grow and develop our knowledge and skills. I can understand how some can fear critical thinking as it can sometimes leave you more confused and unsure of what you thought you knew but that's no excuse not to use or accept it and I ask you to all embrace uncertainty as those that think they have certainty usually tend to be mistaken.
In this line of work there is scarce good quality evidence that allow us to make firm decisions on the best treatment options for our patients for a lot of conditions, and things are changing all the time. We cannot simply just accept that something works or accept that we understand the mechanisms behind it just on face value or due to others saying so, or even because there are some research papers on Google Scholar or PubMed that say so, research can be of extreme variability in quality and results and conclusions manipulated to suit a cause. Finally I'm afraid we just cant say something works based on our own observations and results in clinic as this is subject to our own bias and without knowing it, it can, and does lead clinicians astray, blinded by their own beliefs. Instead we need to use all of the above methods and intergrate them and look at the bigger picture.
Critical thinking can be defined in many ways, I like this one…
“The intellectually disciplined process of actively and skillfully conceptualising, applying, analysing, synthesising or evaluating information from, or generated by, research, observation, experience, reflection, reasoning, or communication as a guide to a belief and action”
Being critical on the other hand is defined as…
“Being inclined to judge severely and find fault”
Thats just being an arse… The key to separating the two is the combination and use of good quality evidence from multiple sources as well as observations and experiences to inform a decision or action, a critic wont have these!
Wanting to view and evaluate evidence and claims made of a treatment is just common sense, it's not skepticism, cynicism or negativity! Ok it maybe skeptical but in my opinion being skeptical is a good trait to have in this business.
The 'critical thinking community' is an excellent site for reading more on what critical thinking is or isn't and how it should be used and I recommend everyone stop by and have a read.
Believe it or not I am open minded, or at least I like to think myself as being so. I am willing to adjust and change my practice and treatment, and I have done so many, many times throughout my career. What I do in my treatment sessions today is so different from 10 years ago its almost unrecognisable, and I beleive that what I will do next year will be different from now, I have to accept this, as I don't have all the answers in fact I have some massive unanswered questions and knowledge gaps, this doesn't make me a bad physio, just an honest one, with a open desire to learn more.
In my opinion this is where a lot of therapists let themselves down, in the belief that they have done a lot of reading around a topic as well as having lots of clinical experience and so feel they have the answers. Some do, but for many this is when they stop, thinking they got it, but it can only take a few months before what they thought they knew maybe isn't so correct after all, critical thinking MUST be a constant ongoing process.
So as more research is churned out as more people use certian techniques or methods of treatment so our understanding evolves and changes, so must we, it's as simple as that and we must be ready to change our practice when the evidence demands it.
However to change my practice I will not just go on the say so of one or two experts or peers, I need two other things 1) evidence, not conclusive nothing ever is, but good strong high quality evidence and 2) time to experience and observe it myself, this is not being stubborn ignorant or arrogant, just reasoned and cautious.
This is a nice diagram from Hanson et al 2012 in BJSM on how research, practice fit together
However, through this adjustment process it usually involves me discarding treatment techniques rather than adding new ones, for example I no longer apply acupuncture, cervical manipulation, ultrasound, or deep painful deep soft tissue treatments such as psoas release, ITB stripping etc as I have found these offer no benefit to my patients, as well as hurts them like hell, and there is now plenty of evidence to support my decision that the proposed mechanisms behind these techniques are flawed.
Occasionally however it does mean I incorporate new methods such as enhancing eccentric loading exercises for tendinopathy with isometrics and heavy, slow concentric/eccentric work, shown to achieve better results, as per Silbernagel's work and clinically I seem to get faster better results than I did before.
I have also started to use kinesio tape in an attempt to reduce pain, and I await the backlash on this, as I know that this may sound like a contradiction as there is scarce good evidence to show kinesio tape does much, but this is where I am prepared to give a new treatment technique some time to establish an evidence base and prove itself clinically. BUT only as long as there are NO risks or potential adverse effects to the patients or if it just doesn't make any common sense, then I won't discard it immediately as I'm aware it takes time for evidence to prove or disprove things, up to 17 years I've once read somewhere!!
So in my opinion we should, must, always be constantly evaluating what a treatment technique is achieving and trying to understand its mechanisms, I do this all the time and I will always question techniques and methods, even well established and so called tried and tested methods such as good old basic massage and joint mobilisations or manipulations?
I do this for manaul therapy because, if I'm being 100% truthfully honest here, I dont think there is much, if any, techniques that I do use that I can say that I wholly have faith in or understand what they are doing at a physical level. This is due to the more I read and discuss these techniques with others the more opinions/views and research/evidence I get from both sides giving me a confusing and muddling mess to pick through. This can be scary and daunting, and somewhat disheartening, as something you believed in so strongly and passionately, and that you could of sworn on your mothers life has been working, suddenly starts to look not so rosey, believe me I've been there many times and I will be there again I'm sure.
I've said this before and I use this quote a lot…
” The more you learn, the less you understand”
But its ok, this is the nature of working with such a complex and diverse thing as the human body, of which we understand very little, as we learn more so must we adapt, not hold onto out dated methods or techniques just because they are comfortable to us.
It is also important to realise that changing your practice and methods isn't an omission of error or of wrong doing, far from it, it is a sign of an excellent thoughtful clinician with a critical thinking mind. I truly believe that if a therapist hasn't changed or modified at least one or more treatment method/technique or approach each year they are not reading enough and/or not critically evaluating themselves hard enough.
Now all that being said, it may come across in this post or if you follow me on twitter that I don't like manual therapy much or that I think it doesn't work, this is not so. I do pull, poke, prod and rub my patients as much as the next therapist in an attempt to reduce their pain and get them moving better, what I do have issue with is the complete and utter bull shit that surrounds manual treatments and the explanations given to patients as to what, how, why they are supposed to be working.
To think that this rubbing and poking does some of the things some therapists claim it does is just not critical thinking, I am going to breifly highlight some of the debates I've had recently next, I will not go into too much depth as many much more intelligent people than me have done far better than I could, and I just want this article to highlight the critical thinking process not the actual subjects themselves but some examples are…
Fascial release: If you think you are 'releasing' fascia by rubbing the skin with your hands or other device please have a stop and just think about that, as Paul Ingraham says on his website and via the excellent @painfultweets the stuff is stronger than steel and Kevlar, if it was any thicker us humans would be bullet proof. If you think just by rubbing your hands over the skin you are physcially changng this stuff then that's just not critical thinking. I'm not saying it rubbing doesn't do something to change the way the person feels or moves, I'm kinda sure it does, it seems to when I do some of the techniques, but thinking it through this has to be through neurological level effects not physical “I've changed fascia's structure”, you just can't explain it that way. For more on fascia this read the excellent @greglehman website here
Sacroiliac Joint palpation: If you think you can palpate symetry of an SIJ and then feel the tiny 2-3 degrees of movement in an SIJ covered by adipose tissue skin fascia and ligaments then again please just stop and critically think about it, read my post on the SIJ here for more on this subject here
Psoas: If you think you can physcially touch the psoas muscle that lies deep in the abdomen next to the spine and so effect the physical properties of it when its under so much tissue and intestines, again please stop and just think about that, all you are doing is mushing people's guts and maybe just maybe doing something neural again, nothing to do with the psoas being released.
Bony landmarks: If you think that you can always find a C4/5 facet joint or a L3/2 spinous process and can apply a constant uniform pressure to that joint each and every time, again please stop and…
Ok, your getting the point now I guess so I'll get down off my soap box!
So there you go my take on critical thinking, as I said eariler this is not me saying that all this pushing, poking, rubbing and pulling a patient is worthless, far from it and I will continue to do just that until I have 1) realised that it makes no difference, or 2) my hands and body give out, for which I hope that is many, many years away yet for both!
I also hope that this has made some people think about questioning what you and others do and maybe start critically thinking a bit more often and a bit more harshly than we probably would like to do.
I also hope that when I do sound critical via twitter or elsewhere that you perhaps can realise I'm not being an arrogant, ignorant arse rather just thinking out loud, if not then I've realised you can't please all the people all the time, that's just life, and I won't lose any sleep over it!
A great quote that I will stick too that I heard from a great critical thinking mind @neiloconnell is that
“if you find yourself agreeing with everyone, you're not thinking hard enough”
Once again thanks for reading
Keep thinking, and try not to be an arse!