False Dichotomies

There are many issues in our profession which seem to present as a division. You are either for or against something, on principle, and that defines you as a practitioner, person, health care provider, etc.

Most of these divisions are un-real. They don’t actually exist and the world is much more nuanced and less black and white. As a part of our superb community of thinking and questioning PTs (Physios) I have been thinking about some of the false dichotomies that exist. Here are 6 of them

1) You should never cause pain in treatment VS you gotta crank on it and push hard to get a change. I am extremely passionate about physios being the part of health care that relieves pain and is a place that people will seek out to absolve their irritations. So I get that side; causing pain in a patient has no place in therapy, it is an abuse of power and privilege. Conversely, encouraging people to struggle through a situation makes them stronger.  It is one of our jobs to fortify our patients to resist the future struggles of the world… in a way. (Read The (f)utility of pain). So I get that side too. Sorry, the side effects of our treatment are that you used your muscles and you are sore today. But I am going to ask you to get on that leg press and exert some force through your body so you know you are alive, feel some struggle and grow from it. The pain of progress is different than the pain of destruction.

2) The APTA is awesome VS The APTA is a slow ineffective dinosaur. False, it is both. I have not been around long enough to have a historical context rich enough to see the whole vision, but I get where we are headed and what is trying to be done. We are trying to place ourselves as Movement Experts into the middle of the healthcare beast. It’s a long term goal. We pay dues and often don’t see immediate rewards because of the long term goals, so it’s hard to get excited. The APTA is also innervated by spacial summation. There are many facets and interests involved across sections and geographic regions. State associations likely move quicker, and with a more meaningful impact to the individual… but thus it goes with governing bodies. 

3)You are all about the brain VS You are only about the tissue. Biased as I am, I am quite neuro-centric. All pain is neurogenic and produced by the brain, yes. The processes of the human are modulated in the brain and therefore that is the end result of change in the body. No problem. Although, we chose to work on the human (and the brain) through the body. We (Physios!… PTs!) are not psychologists, we are (Capital P) Physical Therapists and the tissue becomes very important for many reasons. I can stimulate your somatosensory homunculus with my reflex-hammer (AKA $5.00 IASTM) at the calf. I can dispel fear-avoidance beliefs through novel movement approaches and manual instruction for form and safety. I can provide manual therapy as a calming or pain relief agent… I am treating the tissue… to get to the brain. Neither are to be ignored!

4) Experience is more important because evidence is slow and flawed VS Research is all I need to make any decision. First off, the Evidenced Based Practice pillars include PT expertise, and, the way I interpret it, it is expertise in applying the evidence to your patient. Regardless, practice is extremely important. With more experience (in the PTBT world -view it should be reflective experience) you can notice things quicker, pick up on themes, assess with more efficiency and provide more skilled treatment interventions. You are also more ready for the strange little things that patients bring up, or that insurance companies and lawyers ask of you, etc.  You have hopefully tried and failed at a bunch of approaches and learned along the way. However, it is impossible to not become biased in some way with more experience. (again, thanks human brain!) Enter: Research! The only thing that we humans have that attempts to remove bias from the equation. The scientific process of questioning and testing is valuable beyond belief and holds a proud spot in the basis of our profession. Can research be flawed? Well, it is performed by… humans, so yes, but to ignore the best thing we have to get at the truth, is a mistake. The combination (a theme for this post) is where the magic happens. 

5) You are for manual therapy vs You are against manual therapy. This dichotomy is false as well, the easy answer is: some use it more or less than others. First off, manual therapy is, what? PROM? Shoulder massage? Glenohumeral Joint mobs? Cervical SNAGs? HVLAT? Tactile cues to prevent a patient with CVA / Pusher Syndrome from falling over? Who knows, but most every PT in the world puts their hands on people at some point. Manual therapy has great interactive effects, let’s you gain information about a patient (providing resistance to AROM through a range to find weakness, etc) and can be a really great place to start a patient off on their way to recovery. Certain techniques can provide short term relief that can be built upon and taken advantage of during the treatment session (ex: T-Spine HVLAT followed by scapular TherEx or PNF Rhythmic Initiation progression followed by strength training). That being said, some conceptual constructs of manual therapy are not as robust. Those who are viewed as being against manual therapy are likely not against manual therapy, but against the “claims” and the “why.” PNF and HVLAT are great examples. PNF states that specific hand placement is needed and must be performed “just so” for it to work. I’m sure the patient with a CVA or scapular dyskinesia notices the difference (sarcasm font). But that won’t mean being against manual therapy. HVLAT are often taught as going beyond physiologic ranges and moving joints back in place (out dated chiro model). Current thinking is now leaning towards neurophysiological and interactive effects, and questioning the “why” of these motions and the biologic plausibility of technique concepts does not categorize you as a MT hater. Just a questioner. Most practitioners I know have a developing and nuanced view about what their hands should be doing.

6) Physical Therapy is a business and should be run as one VS Physical Therapy is for the patient at all cost. Again, if you argue that these are the only two possibilities, a HUGE amount of gray between the black and white is missed.  Yes, the doors must stay open, yes running a business is hard (I did successfully for years, and had another that was unsuccessful, as well). Payment for services is hard to come by because of many complex social and political and societal views and perceptual constructs, so focusing on the money, volume and unitz is certainly important, since you want to keep the place running and everyone’s mortgages paid.  That being said, access and quality care, being that it is health care and not DVD players, is very important to society and culture as a whole. We are in the business of people, and people make up our communities. We need healthy, vibrant communities. An answer to this is not yet clear, but certainly the answer to healthcare lies in happy providers reaching the most patients and treating them right and honest. It’s doubtful that all “business PTs” are uncaring or that those “care-y PTs” are clueless about money. 

The false dichotomies could go on… Being for or against Dry Needling, for or against the use of Techs, care or don’t care about Direct Access… and there are certainly individuals who hold a certain one sided view, but they may be missing something.

This post is not meant to squash any discussions or debates on topics. I would actually love some comments about how I am wrong so I could think about it…perhaps there ARE real divisions and within a bubble they are not noticed.

Regardless, debate for the purpose of growth is integral to our future. Progression-through-reflection can occur in real time, verbally, stream of consciousness style in the form of hashing it out over some coffee or brews and trying to figure out the best thing we can do.  More debate means more progress. Best practice of best practice. We all (except the coasters and phone-it-in-ers) are searching for what’s best for the patient, the community, the population.   I’ll say it again, there is Prosperity in our Diversity.

The point being to realize that false dichotomies exist as a logical fallacy… don’t fall into the trap.  Keep debating…

Matt D

7 thoughts on “False Dichotomies

  1. Another interesting way to look at the various dichotomies is the western vs the eastern way of looking at/ understanding the body/ brain/ spirit/ mind.
    Western tradition is cause and effect, perhaps somewhat mechanical. Follows western view of the world as going someplace, there is a history and a future.There is a God directing the way.
    Eastern- more attuned to rhythms,, inward looking, circular life and death patterns Tao and so on. (lots of so on.)
    So, how one sees the world, the body/ mind/ spirit / brain could well affect how one thinks “treatment” should be rendered.

    Liked by 1 person

  2. Interesting topic to ponder, and I appreciate you taking the time to present your thoughts. I think the false dichotomy presents itself all too routinely in clinical and research debates. I’ve attempted to tackle some of the issues, and others, you’ve presented. Your thoughts?


    Usually, if you say always or never you’re wrong…usually. I think a greater focus on some of the nuances, and “it depends” (and what it may depend on) are necessary approaches to discussing some of the issues mentioned. And, of course better understanding of science, philosophy, and debate would be helpful.

    Thanks for spear heading this, you should write some follow up posts.


    • Kyle, glad you dropped those posts here, they go rather well with the questioning (and tone of questioning) I’m trying to produce. I’ve read the 1st 3… on to 4-5.

      I agree with your statements, particularly on the “it depends” and the understanding of debate!


  3. Hey Matt…. Im thinking that the dude with your same last name is probably delivering the greatest insight here.

    Human nature doesn’t like gray… our education system doesn’t like gray.. and yet we try to get science to deliver black and white…and guess what It gives us the gray.

    so back to the wise person up top…solution is within, not without?


    • Jerry,
      Agreed. Within.
      It seems to be a question of comfortability. What is an individuals comfort level with a certain amount (opaqueness, translucency, gradient, shade) of gray. Additionally, what is their comfortability with OTHERs gray tolerance or comfort zone.

      Perhaps we are all color blind.


  4. Pingback: A Year In Review: II | PTbraintrust

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s