We are going to be wrong. For those of you who know me, I am sure that is not how you expected me to open up a blog, but it is true. The scientific method and summation of evidence trump any opinion I will ever hold. As more evidence is presented, opinions and treatments have to change. This does not mean newly published research either. In today’s world, there is such a glut of information that it is impossible to keep up with everything being published. So prove us wrong. Make us better clinicians, but do it with evidence.
We decided to start this blog as a means to discuss how research relates to practice as well as to expose some common fallacies committed when some people call practices “evidence based.” Sackett’s pillars are used as the gold standard: the best research evidence, clinical expertise, and patient preferences.1 Too often Sackett’s pillars of evidence are invoked with only clinical experience as a leg to stand on. Clinical experience is the ability to use clinical skills to identify each patient’s unique health state, diagnosis and risks as well as his/her chances to benefit from the available therapeutic options. It is the sum of what our senses tell us as clinicians and our senses are easily fooled. If you do not believe that, go to a magic show, look at a negative space picture, or jsut raed tihs prat of the snetecne. The problem is that natural history of illness demonstrates that many patients get better, often in spite of what we do.2, 3, 4 This fact leads to clinicians thinking their influence on a patient’s progress is stronger than it is. This is the reason we need the evidence; to show what we are providing as a treatment has an effect. It is called evidence-based medicine for a reason.
Instead of using Sackett, I propose we go back to the original source for debate: Aristotle. See, what we now call the pillars have actually been around since 350 B.C., but at that time they went under the names ethos, pathos and logos—Further proof that nothing much really changes, we just like to give it different names. Ethos is the “clinical experience” pillar that Sackett invokes. Every one of us can name a clinician—with years of experience—who we will readily admit does not employ the remotest concept of evidence. The real philosophical question is “how do we know we are not such a clinician?” So the basis of an argument on ethos supposes that we can answer that question. And here is the rub: once someone establishes his own ethos (taking himself to be an expert or appealing to his own expertise), as too many clinicians are quick to do these days, it becomes even more imperative that we have logos–which in this context is evidence—to stand on. Because no matter how much bullshit there is, people are going to eat it up. 5, 6
Pathos—emotion—is what often turns a debate in to an argument, and not an “argument” in the philosophical sense of a conclusion that is logically supported by true premises. It turns a debate into the frequent pissing matches seen in the comments section of controversial posts on social media. It is in cases like this that we see emotion get involved in a stance, and narratives are often generated. Most times when a blog is written citing something as the “best,” it is appealing to pathos. Scientific debates are settled with the summation of facts, and there is little place for pathos when trying to determine who is ultimately correct. Indeed, we can construct convincing arguments based on excellent use of ethos and pathos, but without logos our “best” arguments are hollow, failing to actually support our conclusions. That is because the third component of Aristotle’s construct—logos—is the most difficult to master, but it is where the Truth lies. Logos requires that we establish when something is truly evidence-based. If we are going to define anything as evidence-based, we must use premises that establish that it is True. If we are going to generate conclusions based on outcomes like subjective reporting, we immediately open up for argument that question the validity of subjective reporting. Problems like this and others are why we cannot reach conclusions easily and even more so why presenting something as “best” without an established premise is not only misleading but wrong.
Logos requires looking for facts, and the truth of the matter is there must be a constant questioning of those facts. That shit is boring. It is the very reason why it is easier to go to a blog than tear through the methods section on Pubmed. Unfortunately, more weight is often placed on the ethos and pathos while neglecting the logos of an argument. For a treatment to be valid within the medical community the premise on which it is founded must be true. In order for this to happen certain steps need to be taken:
1. Terms need to be defined
2. The premise to be studied/discussed has to be clear
3. Quality of evidence must have value (everything works in a case study)
4. The treatment/diagnosis must have a higher effect/incidence than placebo/normal population
First, we need to know what we are discussing. Even concepts like “balance” are poorly defined and too often used to mean different things to different clinicians.7 We discuss concepts like “motor control” and “muscle imbalances” as though they are clearly defined ideas. Before clinicians can ever expand on an idea, we must first establish its definition. What is motor control? Or better yet, what is “the core?” How can we train something that we cannot agree on the limits of?
Despite the need for clearly defined terms, we still have an entire cohort of practitioners basing their diagnosis off of a subluxation construct (it cannot be called a theory as there is no evidence for it)8 or trigger point (which has never been established and cannot be palpated).9,10 This is a false premise, and why we need citations for the justification of diagnosis and treatments. There are entire schools of thought that base treatment off of a diagnostic system that does not work.11 If we do not have evidence, all we can rely on is expert opinion, and, unfortunately, the consensus of expert opinion is still only an opinion. Not to mention that often experts are wrong. We need to seek to find out what is true instead of placing all of our emphasis on being right. There is an interesting tension that arises from the confidence with which we must speak to our patients and the constant insecurity that must be present to keep looking for answers.
Before we can ever call a finding or the sum of our findings aberrant or normal we need to know the base rate of those findings in the asymptomatic population. It is convenient as clinicians to be impressed with ourselves when we go through our special tests with low sensitivity and specificity to come up with the latest diagnosis.12, 13 This is not making our patients any better, but instead giving us an internal satisfaction of reaching a conclusion. However, our conclusion is merely the beginning for patients. The medical professions should be in a business of making patients feel better, not clinicians.
If the differential does not change our treatment, we need to ask ourselves if the minutia really do matter. It is good to be able to differentiate between facet arthropathy and herniated discs, but, truth be told, the intervention is often the same for each.14 The patients need to remove/lessen the stimulus that is contributing to the problem then either start doing something they were not doing or stop doing something of which they were doing too much. Sometimes the treatment should only be us reassuring them with time this issue will heal on its own, but unfortunately that is not good for business.
Healthcare is an awful business model, if we do our job correctly we never see our patients again. We are ultimately in the business of changing behaviors not tissues. Good clinicians realize that we do not have an intervention that can change tissue structure in a short time span. Our job is to create the best possible environment for our patients to heal themselves then mitigate any behaviors that may cause the same issue to return. If we design the best possible program for rehabilitation and an athlete goes back to training the same way is it any wonder the issue manifests again?
As clinicians we are taught to synthesize the data points our patients give us in to patterns in order to reach the appropriate diagnosis. We use inductive reasoning to make a prediction to what we think is the issue, often to justify our predisposed treatment preference. This method of thinking is antithetical to science and is a reason we have numerous papers published where the experiment is designed not to reject the null, but to confirm the experimental hypothesis. To think scientifically is to find all of the reasons an intervention cannot work. The data should constantly be obtained to rule out other diagnosis, not confirm our initial expectations. This means constantly attacking our own beliefs and assessing whether they need to change. It also means accepting the fact that publication bias exists and that studies with findings showing treatments do not work are just as important as those that do.
Clinicians are entrenched in a campaign now to dispel the myth of the herniated disc being a primary cause of low back pain because rushed to conclusions. Imaging showed high rates of disc herniation in patients with pain, so it was originally assumed that must have been the source. We failed to realize the base rate of disc herniation is quite high15 and that there is a low correlation between a herniated disc being present on MRI and pain.16 We did not even think of the possibility that discs could heal themselves.17 Another example now is the diagnosis of femoroacetabular impingement (FAI) being given as the cause of many hip symptoms when the same base rate check reveals a high prevalence of FAI in the asymptomatic population.18
Unfortunately this means we find far more horses than unicorns when conducting an exam. The reason our mascot for the blog is a horse wearing a party hat is because it often us a clinicians that try and make unicorns and an event much larger than what actually is. What we say matters as much, if not more, than what we do with patients. We often complicate our own narrative to patients by adding in verbiage that is just plain false. We do not break up scar tissue or fascia with glorified butter knives.19 We do not magically release tissue. Without a subjective report we are abysmal at finding the mysterious “knots” that too many clinicians talk to their patients about.10,20 We need to stop fitting our version of “normal” to patients and help them realize they are in fact normal. If 80% of the population has had an episode of low back pain would not they be the normal ones and the 20% who have not be the unicorns?21,22 Maybe our first problem as clinicians is thinking that something is wrong.
With this blog we hope to frame issues from a scientific perspective and establish Logos as the proper basis for rehabilitation rather than Ethos or Pathos. People get better. We need to realize this and openly explain it to patients instead of instilling them with fear or doubt in their own ability. We should be facilitating the process, not inhibiting it. We hope this blog will facilitate some discussion amongst clinicians as well—so, please, challenge us. Let’s base our discussion on true premises or go through the literature to establish those that are false. We have never learned anything from being right, but we have never been wrong without a citation.
Oh, and as for that single leg stool….most people probably pictured a faulty three legged stool. There is always that possibility that it was just one big leg (keg) all along and the beverage of choice was causing the problem with the balance. Cheers.
- Silbernagel, K. The Majority of Patients With Achilles Tendinopathy Recover When Treated With Exercise Alone: A 5 Year Follow-Up. AJSM. 2011 30:607.
- Menke, J. Do Manual Therapies Help Low Back Pain? A Comparative Meta-Analysis. Spine. 2014 39, 463-472.
- Steele J, Bruce-Low S. Can Specific Loading Through Exercise Impart Healing or Regeneration of the Intervertebral Disc? The Spine Journal. 2015 15, 2117-2121
- Frankfurt, Harry. On Bullshit. http://www.stoa.org.uk/topics/bullshit/pdf/on-bullshit.pdf 2005
- Pennycook G, Cheyne J. On The Reception and Detection of Pseudo-Profound Bullshit. Judgement and Decision Making. 2015 10, 549-563
- Giboin L, Gruber M. Task-Specificity of Balance Training. Human Movement Science. 2015 44, 22-31
- Mirtz T, Morgan L. An epidemiological examination of the subluxation construct using Hill’s criteria of causation. Chiropractic and Osteopathy. 2009 17, 13
- Quintner J, Bove G. A Critical Evaluation of the Trigger Point Phenomenon. Rheumatology. 2014 270, 1-8
- Hsieh C, Hong C. Interexaminer Reliability of the Palpation of Trigger Points in the Trunk and Lower Limb Muscles. Arch Phys Med Rehab. 2000 81, 258-264
- Werneke M, Deutcher D. McKenzie Lumbar Classification Inter-rater Agreement by Physical Therapists With Different Levels of Formal McKenzie Postgraduate Training. Spine. 2014 39, E182-E190
- Lenza M, Buchbinder R. Magnetic resonance imaging, magnetic resonance arthrography and ultrasonography for assessing rotator cuff tears in people with shoulder pain for whom surgery is being considered (Review). Cochrane Database Syst Rev. 2013 Sep 24, 9
- Hanchard N, Lenza M. Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement (Review). Cochrane Database Syst Rev. 2013 April 30; 4
- Alwaily M, Timko M. Treatment-Based Classification System for Low Back Pain: Revision and Update. Phys Ther. 2015 Dec
- Borenstein D, O’Mara JW. The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects : a seven-year follow-up study. J Bone Joint Surg Am. 2001 Sep 83-A(9): 1306-1311
- Brinjikji W, Luetmer P. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. Am J Neuroradiol. 2015 Apr;36(4):811-6
- Chiu CC, Chuang TY. The probability of spontaneous regression of lumbar herniated disc: a systematic review. Clin Rehabil. 2015 Feb; 29(2): 184-95
- Lee A, Armour P. The prevalence of acetabular labral tears and associated pathology in a young asymptomatic population. Bone Joint J. 2015 May; 97-B(5):623-7
- Chaudhry H, Schleip R. Three-Dimensional Mathematical Model For Deformation of Human Fasciae in Manual Therapy. J Am Osteopath Assoc. 2008;108:379-390
- Maigne J, Cornelis P. Lower back pain and neck pain: is it possible to identify the painful side by palpation only? Ann Phys Rehabil Med. 2012 Mar;55(2):103-11
- Biering-Sorensen F. A prospective study of low back pain in a general population. I. Occurrence, recurrence and aetiology. Scand J Rehabil Med 1983;15:71–9.
- Walker BF, Muller R, Grant WD. Low back pain in Australian adults: prevalence and associated disability. J Manipulative Physiol Ther 2004;27:238–44.