In my PhD studies the concept of the “knowledge gap” is often discussed which essentially means that there are limitations in our understanding of the human body and that what is known is often ineffectively translated into clinical practice (let alone the public). I feel that the latter problem is the more pressing issue and rather complex. Many clinicians don’t consume research often or effective enough, this could be due to a lot of reasons including: interest, access and time cost. Additionally, this may be due to the rather insular method of dissemination of research findings and manuscript publication. Scientific journals are written for other scientists in their given field, which is likely due to the fact that manuscripts are reviewed for publication by fellow researchers who also consume journal articles most often. This is playing to the audience in a certain sense. As a clinician, an emerging academic/researcher, I wonder what needs to be done to address this issue. What are some issues that you all have encountered as clinicians or researchers or students and how do we address this issue? Please feel free to comment and share!
Each time I encounter a post or comment by a clinician regarding an approach to rehab or an explanation for treatment effect or diagnosis, I wonder what experiences led them to their decision and perspective. I analyze this for all posts irrespective of accuracy and my own biases. Overall, the majority of thoughts appear to subscribe to contemporary scientific explanations. However, there is a significant faction within our field that does not. (Bear in mind this analysis acknowledges that there will be slight differences in approaches which can be substantiated by evidence. This is both expected and good for the profession.) Given that for the most part our education/training are similar from primary school through graduate school, access to scientific literature is fairly available to all and clinicians must stay current with CEUs, what are these deviations attributed to? What is the cause for the pseudoscience and in some cases anti-science pervasive within our profession?
However does this matter? Is there actually an ethical dilemma?
Clinical outcomes are important, as are experience and findings of research report typically represent the significant averages. There will always be individual variation and guidelines are meant to be just that, they are not intended to replace clinical decision making. In a sense summary findings of a meta-analysis or clinical practice guidelines should not be viewed as dogma and unalterably infallible. However, ascribing a treatment effect or diagnosis to something factually inaccurate and contrary to the contemporary understanding of physiology is not ideal. Especially considering that an explanation of observed responses to treatment should be disseminated to the patient throughout the course of care. If we are not providing patients and the community accurate explanations for what is occurring with treatment yet they still improve is that ethical is that justifiable?
Case example of many…..
A patient is referred to a clinic for chronic headaches and the clinician provides cranial sacral therapy which results in a positive outcome for the patient. The clinician attributes this beneficial effect from the cranial bones being misaligned and then subsequently being reduced with this treatment. Though the patient’s status improved, the explanation has no substantive evidence to support what was disseminated by the clinician. Is that ethical despite the good outcome? What would the best way to explain the response to this treatment?
Let’s hear your thoughts!
I came across this photo earlier and after viewing some discussions regarding EBP I decided to write a brief post on it.
People often attempt to conceptualize and understand complex topics to fit their world view and biases. This is human nature; as it is difficult to deconstruct information and assess it critically while acknowledging and remaining critical of one’s own biases. This is true for both patients and providers. The attainment of truth and knowledge is a difficult task but necessary. However in this current healthcare system untruths, oversimplifications, obfuscations, conflations and care lacking a trace of plausible evidence is reimbursable. Obscure, esoteric and novel (for the sake of being novel) methods and treatments are also easier to market; as are panacea. Imagine the perspective of the patient and their expectations. This is why the guru and missing link nature is so prominent and pervasive, which is not isolated to chiropractic. Until this issue and it’s multiple components is addressed as a society this issue will continue to perpetuate.
Simply put: “The truth defies simplicity”
The term “breathing dysfunction” is referred to quite often in physical therapy discussion groups/threads as having an influence on musculoskeletal disorders. However it’s often described in a rather nebulous and vague manner with questionable explanations for what is being observed clinically. Similarly, the mechanisms for addressing “breathing dysfunction” are also vague with questionable veracity. As someone with a particular interest in this area, I would appreciate thoughts and opinions on this topic.
Deep slow breathing (DSB) and mindfulness has been shown to improve symptoms of pain, both chronic and acute. Though autonomic responses such as increased heart rate variability and reduced skin conductance (markers of increased parasympathetic tone) have been observed following DSB, their influence on pain rating has been questionable. More recent evidence suggests that the effects of DSB are likely more due to achieving a relaxed state or distraction from the noxious stimuli. Therefore these changes in autonomic activity in following DSB are more likely a reflection of supraspinal activity due to achieving a relaxed or non-threatened state than the cause.
It has also been demonstrated that patients with LBP have demonstrated altered diaphragm position and function, increased diaphragmatic fatigue, impaired maximal inspiratory pressure (MIP or PiMax) and reductions in spinal proprioception. Acute fatigue directed at the inspiratory muscles (primarily the diaphragm) have been shown to alter postural control. Similarly, inspiratory muscle training (IMT), which primarily loads the diaphragm, has been shown to improve postural control and pain ratings in patients with LBP. IMT also has been shown to improve exercise performance; especially in patients with cardiopulmonary disease(s) or disorders. Therefore “breathing and inspiratory muscle function” ARE important and clinically relevant changes can be observed by addressing it appropriately. However, it is important that the mechanisms attributed to clinical observations and treatment effects are based on scientific evidence that accurately reflects what is most likely occurring. It is also critical that these mechanisms are fully understood by clinicians and disseminated accurately to patients.
In summary, clinicians should continue to utilize these techniques as there is decent support for their implementation clinically. However, ascribing these observed effects to inaccurate and unsubstantiated mechanisms is not recommended and neither is disseminating them to patients. A clinician’s accurate understanding of the physiological responses to a treatment is critical to providing accurate and effective education to patients. With patient education being one of the most important components of clinical practice.
This came across my newsfeed, after reviewing it and disappointingly noticing (yet sadly unsurprising) that only 1 physio (Kelly Starrett) out of 100 people was listed. It begs the question, what must we do as a profession to become more influential in this domain? This list of course isn’t from a scholarly organization or a high impact media publication (TIME, NYT, The Republic etc) and it did include Dr. Oz and other such charlatans, which is an approach we should absolutely avoid. However as the “movement experts” It does highlight an area needing improvement. I think we should strive to become more influential in the domain of health and fitness, even just for the sake of drowning some of the the nonsense that is currently being disseminated.
Popular opinion ≠ truth. Stating that a source’s credibility is enhanced by its popularity is a logical fallacy (argementum ad populum). Another important fallacy to avoid is the notion that the duration of how long an idea has been accepted reflects its validity (argumentum ad antiquitatem). The notion that something is true because it can’t be observed to be false (argumentum ad ignorantiam and argumentum ex silentio) should also be avoided. A few things to think about in regards to clinical decision making and practice.
I think we fall victim to these fallacies and others more often than we should, not necessarily with malicious intentions. Humans are creatures of habit and will often reflexively attempt to simplify complex topics and concepts to fit a narrative and world view. I am guilty of this as well, we all have our biases. However realizing this and taking time to think “why do I perform or choose the things that I do” is important to prevent this from perpetuating and having too strong an influence over one’s decisions. Remember the truth defies simplicity.
Do we often over complicate things with our approach to the rehab of MSK disorders? I, likely more than most, firmly believe in the concept “the truth defies simplicity”; however often the causative factor for a problem is rather apparent with an equally simple solution. Too often do I observe approaches based on loose scientific principles or over extensions of human physiology. These behaviors often obfuscate thinking and make treatment more complicated than it should be. The understanding or perception regarding the attributed mechanism for an intended therapeutic effect is important; for both provider and patient. In short, why is as important as what is done or chosen for treatment. Granted there will be variability in approaches based on one’s training and knowledge base; but are our thoughts often too scattered and random when they should be more focused and directed? Does this uncoordinated way of thinking impact our outcomes? Does this matter? Let’s hear your thoughts (pun intended).