Saturday, 3 December 2016

How to create your very own evidence base … in a post truth World

"At one time we had truth and lies. Now we have truth, lies, and statements that may not be true but we consider too benign to call false." Ralph Keys


Hurrah! I hear you say (unless you are a member of the AACP that is … acupuncture is not recommended as a treatment for back pain) the new NICE Guideline - Low back pain and sciatica in over 16s: assessment and management has just been published. That means a group of experts have successfully completed months/years of hard labour, poring through evidence to produce a thorough carefully worded (italics for emphasis) analysis and clear guidance.

Of course, it doesn’t stop there! Then we get commentary and analysis via bloggers. Here’s an example of a nice balanced piece by Neil O’ Connell who was a member of the guideline committee. KarenMiddleton added her view on how the guideline marks an important moment for the physiotherapy profession, emphasising the ‘opportunity to evolve and look again at practice and re-evaluate what is best for patients.’ … the guideline gives clear wording (italics for emphasis) on that, and naturally is disappointing for some, yet welcome to others.

Naturally, as is the way of the World, we get the bloggers, sceptics and Twitterati who also helpfully summarise the guideline, and it is here where things begin to get a little messy. What is clear, to us all in the ‘modern World’ is that there is little time to read long documents, and it is human nature to look for short cuts (so far so good). So in many fields such as medicine, pharmacy and physiotherapy we have the rise of the ‘infographic’ … 

Now, don't get me wrong here, infographics are brilliant, because they are short snappy and summarise long papers in one interesting and attractive figure. I you’ve never seen the work of Yann Le Meur … then you should. The artistry, accuracy and attention to detail, is both impressive and incredibly useful to visual learners. 


not all infographics … how shall I say … meet this exacting standard.

It became apparently obvious to me, that writing an infographic allows the writer to interpret something like a guideline, pretty much any way they want (just as Bloggers and internet commentators do), Herein, lies the rub …

IF the infographic writer, for one reason or another, chooses to alter the emphasis or wording, miss bit out, or get bits wrong … then the reader or recipient can be easily mislead. 

So, you end up with a snap-shot that can misrepresent the original document. Which of course, means that ANYONE can create their own version of the evidence base via the medium of the infographic.

HERE the fun begins!

Below I’ve written a short infographic (well ... some text and a picture) to help anyone create their own evidence base. If you follow the simple instructions, you can make any, paper review, guideline or article say exactly what YOU LIKE … it is a miracle! 

Try it yourself, adjust your favourite intervention, be it CBT, exercise, massage into a slightly bigger font or place on the positive side of the table/graph/pie chart in a slightly bolder colour etc. alter a word here and there (for emphasis/de-emphasis) and before you know it, you’ve changed the message of the original. You can even miss stuff out if you like, say radio frequency denervation or manual therapy (it is entirely your choice), if that’s is something you don’t particularly subscribe to.

Indeed ... if someone from the AACP had thought of it they could have re-inserted acupuncture into the LBP guidelines and lots of folk would never have noticed (cos’ they don’t have time to read the source document). That would of course, be disingenuous, but hey ... politicians do it daily, and we wouldn’t have had Iraq, Brexit or Donald Trump without a little (or more) distortion of the truth.

Where does this leave us? And why did I even bother to put pen to paper?

Well it requires us to have a realisation that we are in the ‘post-truth era’ as detailed so well by Ralph Keyes in his book The Post-Truth Era:Dishonesty and Deception in Contemporary Life. Keyes states:

‘At one time we had truth and lies. Now we have truth, lies, and statements that may not be true but we consider too benign to call false. Euphemisms abound. We’re “economical with the truth,” we “sweeten it,” or tell “the truth improved.” The term deceive gives way to spin.  At worst we admit to “misspeaking,” or “exercising poor judgment.”  Nor do we want to accuse others of lying.  We say they’re in denial.  A liar is “ethically challenged,” someone for whom “the truth is temporarily unavailable.”’ Ralph Keyes

Furthermore he states …

‘We can only understand the motives of such dissemblers by examining the sea in which they swim. Trends ranging from the postmodern disdain for “truth” to therapeutic non-judgment encourage deception. There is much incentive and little penalty for improving the “narrative” of one’s life. The increasing influence of therapists, entertainers, politicians, academics, and lawyers, with their flexible code of ethics, contribute to the post-truth era. So do ethical relativism, Boomer narcissism, the decline of community, and rise of the Internet.’

So there you have it folks … we have to adjust our radars, improve our awareness, be on our guard, even occasionally take the time to read a source document. Because, sometimes those nice folks who wrote that blog may just have written it to fit their own biases, or particular agendas, and in the same way, the handy visual snapshot of reality ... the infographic ... has sadly fallen foul of exactly the same concept. 

The dissemblers are amongst us, and I truly don't know why they behave that way.


Now  ... just a brief word on sceptics ... AND pseudo sceptics

The medical World has its fair share of sceptics or skeptics (as they are known in the USA), Ben Goldacre of Bad Science, is perhaps one of the most well known examples, Edzard Ernst is another. These brave souls, speak out on any issues from, basic bad science, global warming, Government policy, Prince Charles and his promotion of homeopathy, through to the risks of spinal manipulation etc. 

Good sceptics adopt an open minded approach and use science, debate, exposure (of bad practice) and apply critical examination and inquiry to all sides (including their own). 

Here's an example; Ernst has been a long time critic of alternative medicine (AM), and frequently adverse events (e.g. death after SMT) and general poor scientific practice relating to all sorts of disciplines within AM. These range from the more unconventional stuff like 'energy healing', and 'spiritual healing', through to say 'slapping therapy', and perhaps the more conventional, such as acupuncture. As such, he is commonly aggresively vilified and challenged by proponents of such therapies. His response is kindly, gentlemanly debate (often in the face of virtual abuse), use of science, critique, statistics etc. BUT when evidence comes along to challenge his World view on a topic, he has the good grace and conduct, to modify his view according to the developing and changing evidence base, or at the very least, air that evidence. 

Of interest to some physiotherapists (either historically or practically), MASSAGE had been a target of his for a number of years, until a new paper caught his eye and he wrote this and then later, this. Ernst is an example of how a GOOD honest sceptic is able to adapt their paradigm to new evidence and update their hypotheses to fit the data. In physiotherapy, SOME of our emerging breed of bloggers, podcasters and self-proclaimed sceptics are able to do that, and do it very well. SOME appear to default to the habits of pseudo-sceptics.

Pseudo-sceptics ... tend to:
  • Persistantly judge as false, and debunk anything that contradicts their paradigm.
  • Are partially interested in truth, evidence and facts, but MORE interested in defending their own views/stance.
  • May fail to update their paradigm to incorporate new evidence, and deny or bury data which doesn't fit their view.

Sceptic or denier?

'A sceptic will question claims, then embrace the evidence. 

A denier will question claims, then reject (or bury) the evidence....'

and for a brilliant commentary on pseudo-skepticism by Marcello Truzzi go here.

So be on your guard people … it's a tough environment out there, and distinguishing truth from fiction in a post-truth World ain't easy ... false news, pervades every aspect of the internet, even those sources, you thought you could trust, AND relies entirely on a passive (non-thinking) click of a button. Those who use it to their advantage know that, and you should too ... if you don't already! 

After all, that is what brought us Donald Trump. Good luck folks.

I’ll leave you with the wise words of Ralph Keyes who vocalises this much better than I ever could …

‘Post-truthfulness builds a fragile social edifice based on wariness. It erodes the foundation of trust that underlies any healthy civilization. When enough of us peddle fantasy as fact, society loses its grounding in reality.  Society would crumble altogether if we assumed others were as likely to dissemble as tell the truth. We are perilously close to that point.’ Ralph Keyes

Be careful out there folks … words matter, and semantics are important AND that is the TRUTH

HT to Woody  Guthrie for being an inspiration -  "It's a folk singers critical thinkers job to comfort disturbed people and to disturb comfortable people" ... see what I did?

Author: Alan J Taylor is a writer and critic who thinks about stuff and works as a Physiotherapist, University Assistant Professor and Medico-Legal expert witness ... The views contained in this blog are his own and are not linked to any organisation or institution. Like Bukowski, he 'writes to stay sane'.

Tuesday, 23 February 2016

Death following a neck injury: What can we learn from the case of Katie May?

This commentary was originally written as a general interest article for publication on a Web news page. For one reason or another it was not published ... So here it is, in a modified Blog format.

Katie May, a 34 year old Playboy model and entrepreneur, died on February 4th 2016 following a stroke. Whilst the details are sketchy, media reports of a neck injury during a photo shoot raises questions as to how a fit healthy 34 year old, could go from an apparent neck strain to a fatal stroke in a matter of days. This report takes look at the mechanisms of early stroke and considers what we can learn from the case.

Neck pain is a common complaint that is thought to affect around 10-13% of the population. However, most patients do not have a life threatening condition. That said the cervical blood vessels can be susceptible to injury. This was illustrated graphically by the tragic death of Australian Cricketer Phillip Hughes. Hughes died from a sub arachnoid haemorrhage (bleed to the brain) following a blunt injury to a blood vessel in his neck from a cricket ball.

The blood flow to the brain is carried by two small vessels at the back of the neck called vertebral arteries, and two larger vessels at the front, called the carotid arteries. The carotids carry around of 80% of the blood flow to the brain. It is well known that any of these blood vessels can be injured by trauma or affected by disease. It is well known that the early presenting symptoms of arterial dissection may be neck pain or headache and that ischaemic symptoms may not develop until later.

A complex anatomical region ...

So, how could an apparently fit, healthy female, suffer a stroke leading to death at the age of 34?

The complete picture of exactly what happened in this case remains unknown, but we can learn from past experience. There are a number of potential scenarios.

One scenario is that like Phillip Hughes, Katie May had perfectly HEALTHY blood vessels that were injured internally (arterial dissection) by an ‘awkward’ fall during a photo shoot. What happened thereafter remains open to speculation. At that point ANY intervention whether it was advice (to keep moving), pain management/education or manual therapy/manipulation, may have ended with the same outcome.

It remains unexplained how some dissection pathologies resolve yet others go on to lead to stroke or death. It is thought that this may relate to variety of intrinsic conditions linked to connective tissue disorders and clotting factors. In addition, extrinsic factors may also play their part. A failure to recognise the signs and symptoms (assuming there were any) of a developing pathology in accident and emergency, at the GP practice, or under the care of a musculoskeletal therapist (Physiotherapist, Osteopath, Chiropractor) may be also be associated with fatal consequences. A common medico-legal scenario, is a delay to appropriate triage, in order to commence a trial of management or specific treatment.

 Thrombotic stroke - image en.wikipedia.org550 × 800Search by image 

A second scenario of many, is where a person develops musculoskeletal neck pain insidiously or via a minor trauma and seeks the attention of a manipulative therapist, such as a Chiropractor, Osteopath or Physiotherapist. Katie May Tweeted that she was going to see her Chiropractor, though no detail has been released. However, the wave of assumption and speculation implicating Chiropractors, could well be entirely unfounded as this single case study clearly illustrates. 

The status of the blood vessels at the time of ANY consultation, may be either healthy OR unhealthy. Unfortunately, without sophisticated equipment, there is no way of knowing whether vessels may be ‘weak’ or suffering from underlying disease such as fibromuscular dysplasia or atherosclerosis (rare in the younger patient). This is one of the reasons that manipulation in particular, has been called into question. At best the science remains equivocal. A recent systematic review found no association and suggested that, "the relative risk of ICA dissection after cervical spine manipulation compared with other health care interventions for neck pain, back pain, or headache is unknown". However, critics argue that spinal manipulation to the neck may injure vessels, leading to stroke.

Neck manipulation has many descriptions, but generally involves a high velocity manoeuvre, outside the control of the patient, which may produce a click or crack. There is evidence to suggest that for acute/subacute neck pain, cervical manipulation provides better pain relief and functional improvement than medications such as varied combinations of NSAIDs, analgesics and muscle relaxants. However, the caveat is that this benefit, may not be entirely risk free. Furthermore, it is suggested that the actual number of adverse events (injury, stroke, death) may be massively under reported


Could the risk be reduced?

The debate on the safety of manipulation has not been helped by the lack of agreement on the risk of blood vessel injury following treatment. Some reports suggest ratios between one in 50,000 to one in nearly 6 million manipulations, though as mentioned, many question the accuracy of this data, citing up to 100% under-reporting. A review of 134 case reports, published in 2012, said, “there was potential for a clinician to prevent 44.8% of adverse events (such as stroke or death) associated with manipulation”. The authors suggested, “10.4% of the events were unpreventable”. Interestingly, the patients who died had continued or excessive spinal manipulation, despite the fact that they were not responding to treatment, or their symptoms were worsening.

Despite RCT reports that in apparently healthy vessels, manipulation to the atlanto-
axial joint does NOT appear to increase mechanical stress on the vertebral artery, it remains unknown what the affect might be on diseased, weak or already dissecting vessels (vertebral or carotid).

As it stands, scientific knowledge can neither accurately quantify the risk associated with neck manipulation, nor establish an unequivocal link between manipulation and adverse events. A 2016 physiotherapy publication, a profession that has been prominent in the field of neck risk assessment, suggested that, at best, “early recognition of injury to blood vessels” may reduce the occurrences of inappropriate treatment. This raises the important question of what exactly is 'inappropriate treatment'? Whilst manipulation may have been demonised by some, it is important to understand that blindly defaulting to ANY favoured intervention in the absence of sound clinical examination and risk assessment ... may lead to adverse outcomes in the presence of arterial injury.

Could tragic events like this be prevented?

Disappointingly, the complexity of the human body and mind, dictates that the answer will vary from case to case and clinician to clinician. It remains essential for ALL CLINICIANS to retain an index of suspicion for arterial injury in cases of trauma, be cognisant of ‘red flags’ and apply appropriate clinical reasoning and examination procedures. A default to, a single school of thought or approach (whatever that may be), may lead to delays to triage, inappropriate management and potential medico-legal consequences. 

Atypical, worsening presentations, with OR without subtle ischaemic symptoms may alert the clinician to the presence of arterial injury. The diagnosis of arterial dissection rests on a careful clinical history, physical examination, and targeted ancillary investigations. Clinicials should be cognisant that delay may be fatal.

What do we all have to learn from cases like this?

1. Retain an index of suspicion for vascular injury in trauma cases. 

2. Know your anatomy and pathophysiology.

3. Hurt does = harm, in some cases

4. Examine and question the patient in detail.

5. Have, and retain vigilance for ‘Red Flags'.

6. A DELAY to appropriate management, is a common root cause in many medico-legal cases.

 ... There is NEVER absolute certainty


HT to Woody  Guthrie for being an inspiration -  "It's a folk singers critical thinkers job to comfort disturbed people and to disturb comfortable people"

Author: Alan J Taylor is a writer and critic who thinks about stuff and works as a Physiotherapist, University Assistant Professor and Medico-Legal expert witness ... The views contained in this blog are his own and are not linked to any organisation or institution. Like Bukowski, he 'writes to stay sane'.

You'll find him mostly on Twitter