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What Evidenced Based Practice Is Not

The following post is inspired by Stu McMillan’s “Evidenced Based Coaching” piece on Brett Bartholomew’s site.  McMillan’s article is intellectually honest, nuanced, and refreshingly uncontroversial.  His thesis is that practical experience and science are complimentary, not dichotomous, because neither paradigm is comprehensive in itself.  In full disclosure, Stu and Brett have greatly influenced my clinical thought process and I am grateful for their transparency.  They actually demonstrate what they do with their athletes, which leaves them open to criticism when somebody’s lumbar spine visibly budges while performing a maximal effort lift in one of their Instagram videos.  McMillan’s article was primarily directed at the coaching profession but is equally applicable to physiotherapy.

“Talking over the heads of the less educated has become an enjoyable pastime for many (people); this practice is simply self-indulgent ego massage, and does nothing to move the profession forward”.  Stu’s statement here transcends the coaching profession.  Currently, it seems that the easiest way to coronate oneself in physiotherapy is to incessantly pontificate on social media about how antiquated and unscientific other clinicians are while pleading that the less enlightened adhere to the “evidence”.  These abstract appeals for better “science” are often devoid of tangible alternatives, but include arbitrary links to Pubmed abstracts without any context or qualification.  The Pubmed Olympics is one of the most unproductive practices on social media.  Cutting and pasting a few Pubmed links is not the intellectual equivalent of a finishing move in professional wrestling or an 80’s action movie.  Professional dialogues are not about winning and losing but about critically and objectively evaluating ideas.  Unfortunately, the number of Pubmed citations, no matter their relevance, in a Facebook or Twitter thread has become synonymous with victory, thereby advancing a preordained narrative more than professional growth.  Not all consumers of research bastardize information like this but the practice is prevalent enough that it dead-ends many potentially productive dialogues.

Arbitrary Pubmed links ≠ Stone Cold Stunner or Lincoln Hawk going Over The Top

Demanding that other clinicians practice more scientifically or with more empirical vigor in the absence of specific guidelines is a safe way to establish social media credibility because it’s essentially irrefutable.  It is too easy to be critical of others when the discussion is framed in such a way that the critic can never be wrong.  Principles and abstract recommendations are less incriminating than details.  Fine-tuning the details requires professional dialogue.  The status quo in physical therapy, or any medical profession for that matter, is intolerable because failure to apply knowledge perpetuates preventable harm.  Consequently, professionals should demand accountability from one another.  Professionals should also welcome respectful challenges.  Anybody who is willing to criticize another professional’s plan of care or clinical reasoning process in a public forum, however, should be willing to demonstrate what he/she would do instead.  Ideally, that alternative would be superior in terms of its theoretical and empirical plausibility and advance the discussion.  Regardless, that type of transparency builds trust and helps to engage other people who might positively contribute.   Rhetorical pleas for better science do not advance evidenced based medicine even though physiologically sound principles and empirical knowledge are the foundation of robust clinical practice.

There is no better means of exploring unexplained phenomena than the scientific method.  The scientific method is so powerful because it minimizes the influence of context and confounding factors on the variable under scrutiny.  This reductionism allows for more rigorous protocols.  That same reductionism, however, reduces the generalizability of a particular study because context is regarded as noise that must be filtered out.  In human endeavors, disregarding context generally yields incomplete solutions to problems.  Reductionist elements are still necessary components of complex systems.  Despite the organizational and cultural issues that may contribute to, say, a manufacturing oversight in an aircraft, the broken part still needs to be fixed or replaced.  While the whole isn’t the sum of the parts, knowledge of the whole is not sufficient without understanding how the parts work in isolation.

Moreover, the utility of these parts is contingent upon relevant questions and categorizations.  In sports medicine, how revealing are diagnoses like patellofemoral pain syndrome, non-specific low back pain, and sacroiliac dysfunction really?  How much insight can we really hope to gain from studies contingent upon these types of frameworks?  When structural pathology is not the pain generator or performance limiting factor, do anatomical diagnoses allow for reasonable assumptions?  We can know, for example, which exercises elicit the highest EMG activity in a particular muscle but neurological insults notwithstanding, when and why is more electrical activity in a specific muscle desirable?  The ability to measure something in the absence of additional context doesn’t always render the information meaningful.  As examined here, when the right processes are in place, myopic distinctions are less necessary.

In any biological system, some degree of variability is necessary to achieve a particular outcome.  Asystole (no electrical activity/too little variability) and ventricular fibrillation (completely disorganized electrical activity/too much variability) are both lethal heart rhythms.  The former condition is characterized by system rigidity and the latter condition by system chaos.  Both conditions are maladaptive in the gravest sense.  The point here is that the polar opposite of reductionism is not desirable either.  Without boundaries, everything matters to the point that nothing matters.  In physical medicine, it’s not uncommon to hear people say, “Everything is connected.”  That statement is reasonable to a point but without boundaries, one could justify treating jaw instability with a big toe mobilization because connective tissue is effectively continuous.  Anything is possible but some phenomena are more probable and reasonable than others.  Rejecting science for its inherent reductionism is just as egregious as misusing it to elevate oneself politically at the expense of others.  When there are no boundaries, one can never be wrong.  Extremism of all kinds promotes certainty at the expense of truth.

“Jacques Cousteau could never get this low” –Wu Tang Clan

The dots of information generated by the scientific method, including those from randomized controlled trials, need to be connected when applied in the broader context of clinical practice.  While some of these dots can be connected with advanced metrics, human beings still need to draw meaningful conclusions from the pool of scientific data (e.g. think).  That the individual dots are themselves incomplete does not justify the haphazard connections and flawed inferences some critics of reductionism make.  In other words, the reductionist nature of science does not excuse irresponsible application of the information that we do know.  However, connecting these dots, often across multiple disciplines, provides the most profound insight.

Too many buckets to carry

Connecting these dots is where the art of science and medicine cannot be denied.  While science is the most objective means of inquiry we have, it is not devoid of subjectivity.  Professional dialogue, collaboration, and accountability are essential to maintain subjective integrity in medicine.  Effective collaboration is only possible when science is not used as a platform for dogmatism but as a conversation generator.   Moreover, intellectual honesty amplifies science’s utility.  The purpose of science is not to discredit other professionals or to create a façade of social media expertise.  Science is not a hashtag whose object is emotional validation or the elicitation of likes and emojis.  Science answers current questions to help generate better ones.

Albert says “Don’t smear science”