One of the best FB comments

TheKettleBellPhysioBlog, Uncategorized0 Comments

Possibly one of the best FB comments on a thread I’ve seen:

“It’s absolutely true that skeptics have to be willing to consider new ideas when sufficient evidence to demonstrate their plausibility is presented. As skeptics and clinicians, that also means we have to be willing to accept that some of the ideas we have in practice are also based on faulty logic or inaccurate assumptions.

“You guys have a LONG way to go to convince me that TPT are BS”

^ that isn’t really how science works. We shouldn’t have to try to convince you of anything – as a self-identified scientific skeptic, you should look to science, logic and evidence to establish whether an idea is plausible. A lack of those things doesn’t mean that an idea is “wrong”, it just means that we can’t say it’s “true” either, and shouldn’t base our clinical decisions on it as a result. Science deals in plausibilities, not absolutes, which is why how consistent an idea is with established, mainstream science impacts how plausible we should consider that idea.

In the case of trigger points (or any other hands on approach in practice), that means considering two completely distinct concepts: the outcomes of the treatments, as well as the proposed mechanism of action. Both should be plausible based on current understanding of human anatomy, physiology and pathophysiology, and consistent with the evidence.

The fault here, and this is true with A LOT (arguably most) hands on approaches, is that therapists tend to conflate outcome of treatment as evidence of mechanism of action. Whether or not a treatment had an outcome, especially when the outcomes are based on subjective experiences such as pain perception, is *never* validation of mechanism of action. We can often say with some degree of confidence (but never certainty) that a treatment did or did not reach a desired outcome – say, reduced pain – but we rarely, if ever, can say that the outcome was caused by X. In the case of trigger points: we can usually feel confident in the outcome when a client reports less pain, but that outcome doesn’t, in any way, confirm that trigger points exist, or that if they do, they contributed in a meaningful way toward the outcome. We don’t, in a manual therapy practice, have the tools or skillset to isolate a mechanism of action in that way.

To illustrate the issue of conflating outcome with mechanism, and relying on clinical experience alone:

I could treat 1000 patients who had colds. For the sake of argument, I could even divide those 1000 patients into 5 distinct groups, and I would treat each group with a different modality or treatment approach in my practice, and record the results of each group. In almost every (if not every) case, the patients would recover from their cold within a relatively consistent time frame after receiving treatment. In fact, it’s also very likely that the majority of those patients would report feeling better immediately after treatment, even if not recovered completely.

I could even compare the results of the groups, informally or formally in a comparative study, to show which technique or modality seemed to be associated with the best outcomes (shortened duration of the cold, greater alleviation of symptoms post-treatment, etc.). I could try to use these data to justify a supposition that my treatments “detoxified” the patient, leading to a “heightened immune system”, which got rid of the cold. I.e. I could say “it worked, therefore the idea that the effect is caused by X is true.”

However, none of the above would actually demonstrate evidence in favour of my supposition. As we know, colds are self-limiting in nature, and would resolve with time completely independently of the treatment. Despite all the abundance of evidence I gather in this way, and clinical experience I have treating clients with this condition using X modality(ies), and the painstaking efforts I took to organize my results into a study, my rationale behind my patients’ outcomes would still be incorrect, and no number of positive outcomes would be sufficient to validate my supposition of “detoxification”. I would effectively just be reinforcing my own confirmation bias, rather than conducting an actual scientific inquiry.

Does that mean that none of my patients experienced positive outcomes – that because the underlying mechanism of action was indeterminate (or definitely inaccurate, as with the above), that the treatment had no value for those patients? Of course not. Questioning or rejecting the plausibility of the mechanism of action doesn’t suggest the treatment wasn’t effective or of value to the client. It’s simply the “why” it (seemed to) have that outcome that is up for debate. If trigger points don’t exist, does that mean that the trigger point treatments you provided didn’t have good outcomes? Of course not, it just means that some other mechanism of action was at play. It’s this conflation of the two concepts that tends to get therapists upset when a mechanism of action is challenged, because they read it to mean their treatments “didn’t work”. It’s especially challenging when the mechanism is totally unknown – whether or not the questioner has a plausible alternate explanation for mechanism of action doesn’t have any impact on whether a particular mechanism of action should be considered plausible.

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