The Inverted Pyramid

This concept is one that was introduced to me back in my postgraduate study days at the University of Western Australia. It recently came to mind again and is something that I find very useful. I plan to introduce it to this blog for the next few posts. Depending on how well it is received I might keep the theme up.


There are a few different interpretations of this concept, but the basic premise is that the “top” part of the inverted pyramid is the “most important” information, whilst the “bottom”, or “pointy bit”, of the pyramid is the least important information, the “fluff”.

I think we can apply this concept to all aspects of physiotherapy. We might take the subjective exam and decide what the “most important” information is and make sure we cover at least this in our initial assessment of patients. The “pointy” stuff can be of a lesser priority/importance, and perhaps wait until subsequent consultations. Maybe we don’t need to worry about it sometimes!

Similarly with the physical examination, perhaps we make sure we focus on the real important aspects as a priority and not “fluff” around at the “pointy end” focussing on the least important aspects of the assessment. We also shouldn’t be using the “pointy end” information as a priority to formulate the diagnosis and classification, as this is the least important information and not the crux of the diagnosis. No doubt it is helpful, but it is the least important information.

I think we can also apply this concept to treatment. For example if we can see in the research literature that a certain “treatment” or “regime” seems to be generally more beneficial to patients with condition “x” then perhaps we should consider that particular “treatment” as the best one to instigate initially because it is at the at the top of the inverted pyramid (have I confused anyone yet……). Other, lower evidence, treatments go to the “pointy end”. Yes expert opinion (i.e. yours and mine) is low level evidence. Don’t forget this pyramid:


This version made me laugh, but I know clinicians that use it…..:


See this link for the original post on this pyramid. Brilliant read.

So anyway, stay tuned for some “inverted pyramids”.

Thanks for reading.

About the Author:

Mark is a Specialist Musculoskeletal Physiotherapist who consults at both Insight Physiotherapy and Pain Options, in Perth, Western Australia. He specialises in the assessment and management of persistent/chronic musculoskeletal pain. In addition to his clinical role he maintains regular involvement in education of the profession having held a Teaching Fellow position at the University of Western Australia for 10 years and regularly presenting at courses and seminars through the Australian Physiotherapy Association and private education sector. Mark is also a Facilitator for the Australian College of Physiotherapists Specialisation Training Program and a Branch Councillor on the Western Australian Branch of the Australian Physiotherapy Association.

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