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Contemplating the use of direct vs. indirect research in manual medical practise. Is your ‘science’ strong enough?

June 27, 2013

@DrAndreoSpina: The only absolute certainty in science is that what we know today pails in comparison to what we will know tomorrow.

For those of you who know me and/or follow my ‘material,’ you will attest to the fact that I believe scientific inquiry to be the most important activity for the growth, and expansion of manual medicine (as well as everything else for that matter). However, as is the case with any institutionalized endeavor, we must always be on guard not to develop dogmatic practices under the shield of “science.” Doing so will ultimately limit the growth of knowledge and retard progress.

In the world of manual medicine, there seems to be a growing presence amongst our colleagues of those who are attempting to solidify their approaches on the sole basis of direct, published research. By ‘direct,’ I refer to studies that unswervingly look at the application of a particular therapeutic technique and the results that follow in a controlled (often randomized) fashion. Although this attempt is more commendable, in my humble opinion, then the polar opposite method of maintaining ignorance of the research and opting to utilize ‘unfalsifiable’ theories, both are, by definition, dogmatic.

dog·mat·ic (dôg-mtk, dg-)
adj.
1. Relating to, characteristic of, or resulting from dogma.
2. Characterized by an authoritative, arrogant assertion of unproved or unprovable principles.

While the latter view is more obviously dogmatic with its utilization of ‘unprovable’ principles, the former view, under the umbrella of “research,” asserts that even the possibility of merit in non-directly researched methods/techniques simply does not exist. This sentiment is equally unprovable and in fact has been demonstrated as false on several occasions by the immergence of new evidence.

A good example of this is the often-propagated ‘stretching myth’ of its ability to prevent injury. This view was held in the minds of many learned people to be scientifically sound for many years before the topic was actually scrutinized via research based inquiry. Thus in this example, there was a dogmatically held ‘belief’ that was disguised as being scientific by the highly un-scientific assumption that common sense always holds true.

Another example is the utilization of cryotherapy for the reduction of inflammation. Students are indoctrinated to believe that this method of therapy is ‘settled’ in terms of being scientific fact. However, examination of the literature paints a far more ‘blurry’ picture (as it does for the entire ‘RICE’ approach). This is not to say that its utilization should be shunned due to the lack of direct evidence (which would in fact contradict the premise of my argument), rather that it can/should be utilized with the knowledge that its ‘proof’ is founded on indirect evidence. In other words, the evidence that substantiates its use is built upon research that looks at its physiological results, as well as its historical clinical utilization/effectiveness, rather than RCT’s, and/or meta-analysis on the topic.

Using indirect evidence in no way retracts from the usefulness of a particular approach. In fact, most manual medical practice is based on concepts that are not directly researched. This fact simply means that the onus for evidence to justify its practice must rely on a ‘lesser’ level of scientific inquiry (Clinical experience/Case Reports vs. RCT’s). Alternatively stated, it must rely on the ‘best’ evidence available.

‘Evidence-Based Medicine’ and ‘Research-Based Medicine’ are not synonymous. When a patient is in your office in pain and is looking to you for council and advice, it is not enough to say that there is no research to justify any attempts at helping you at this time. That is NOT an evidence-based approach. Nor is it evidence based to denounce a procedures and/or techniques whose theory is built on a strong basis of indirect evidence. For example, there is a current trend to denounce soft tissue therapeutic approaches due to a lack of “direct” evidence. In its place many are utilizing ever more complicated rehabilitation/exercise prescription. Note first that many of these approaches are equally as unfounded in ‘direct’ science. They are simply ‘hiding’ under the basic/general premise that “exercise” has been proven to be useful for ‘many things.’ Thus the level of evidence, which on one hand is being used to denounce soft tissue therapeutic application, is being used to justify the utilization of exercise/rehabilitative principles. This is blatantly contradictive. In reality, both of the aforementioned approaches can be justified in the context of manual medicine via a plethora of indirect evidence written on each topic. Note that much of this evidence resides in the realm of cellular biophysics/morphology, which are areas of biological science that are often ignored in manual medical circles (However, this is another discussion altogether).

It should be clear that my arguments presented above do not suggest that all techniques are created equal. Nor are they meant to suggest that any and all ‘systems’ should be taken seriously simply based on opinion, nor the sole experience of a single practitioner. To believe so would be unscientific. It is the job of PRACTITIONERS to justify their approaches. For example, one can utilize the available indirect research to justify manipulation of the Costotransverse joint by extrapolating from the research of how other similar synovial joints respond to manipulation (e.g. lumbar spine facet joints). Similarly the use of ice for acute injuries can be justified by look at research that demonstrates its ability to reduce blood flow (hence inflammation) and pain. To use an example outside the scope of manual medicine, we do not need direct evidence to accept antibiotics when suffering from bacterial meningitis, as it is enough to assume that this bacterially caused ailment would be best combated with medicines that have been shown to have an ‘anti-bacterial’ function. These are examples of USING research to create a best evidence approach. We cannot however make claim simply that manipulation is a “good thing” and thus can be used for the treatment of anything simply owing to the fact that has been shown to be “good.” This is not an evidence based thought process.

We must maintain a healthy skepticism of proposed techniques and constantly question their validity in the light of the most recent research pertaining to the topic. This places the onus on the technique ‘developer’ to justify the approach as the burden of proof lies with the party making the positive assertion. Acceptance and promotion of an approach can/should only be garnered when contemplating the strength of the argument created. If an argument is not offered (many examples currently come to mind), then the technique should be cast off with the same ‘ease.’ As the great Christopher Hitchens offered, “That which can be asserted without evidence can be dismissed without evidence.”

At the same time, we should not denounce IDEAS due to lack of ‘direct’ evidence. To do so would be to halt progress entirely as ideas ALWAYS precede research. To stifle creativity is to kill the scientific process. Thus when questioning an idea or technique in manual medicine, we should not demand for “proof,” but rather should demand “justification.” These terms, contrary to popular belief, are not synonymous.

I’ll end with a question posed by Einstein, “if we knew what it was we were doing, it would not be called research, would it?”

Dr. Andreo ‘Dre’ Spina

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3 Comments leave one →
  1. June 28, 2013 3:16 pm

    I think you’re using too much professional courtesy with this one Dre. Say it like is: If you have an idea or theory as to why we have pain you must be prepared to defend that idea with credible evidence. Not just “I’ve seen it work in my clinic for years so that’s why I continue to do it” without ever giving any sort of real justification….

    am I getting what you’re saying here? This was one of the harder posts to follow

    • July 1, 2013 1:32 pm

      Really what I am saying is that there are some individuals whose demand for ‘direct’ evidence only serves to stifle progress. One cannot simply ask “where is the research for what you are doing,” but rather should demand “where is the evidence for what you are doing?”…or, can you “justify” what you are doing. As I noted in the commentary, ideas always precede research. We must therefore encourage a free flow of ideas so long as the ideas are grounded in evidence. This evidence can be ‘indirect’ evidence and does not have to rely on research directed specifically at the topic. For example, we have evidence that cryotherapy works based physiological mechanisms, its ability to reduce pain, its ability to reduce blood flow…but there are no large scale studies looking specifically at its effects in a real controlled manner. This study is surely needed…but a good ‘evidence guided argument’ for its implementation is possible with indirect research.

      I hope that clears it up

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