Forget gurus, the cult of the evidence-based blogger has taken over ... 'Biased BLOG Bingo'

WARNING! This blog may contain traces of humour ... 

If you suffer a sense of humour deficit ... DO NOT READ ON!

Some time ago now, I had the pleasure of reading an excellent article by Will Self called ‘The awful cult of the talentless hipster has taken over’ … 

Whilst I didn’t necessarily agree with his diatribe entirely, I lapped up the trademark dour humour, empathised with his view and thoroughly enjoyed the read. Then in a bizarre moment of thought association, my mind turned to my own area of interest, Health Sciences and evidence based practice (Physiotherapy in particular) … though this undoubtedly pertains to medicine and all other areas of health care ... I began to ponder ‘the cult of the evidenced based blogger’, which now appears to pervade the zeitgeist of our increasingly confused World

Don’t get me wrong, our World is important (to us … and the people we care for, hopefully) as is the evidence. I like and respect (most) bloggers (cos’ they’re out there), I blog myself … But sometimes I begin to wonder about the whole process, or perhaps question the motives of the bloggers (myself included).

Bloggers and Twitterati, these days are ubiquitous; everyone seems to be having a go and some appear to be very authoritative. Yet blogging is a strange and precarious pastime/hobby/profession, which is both time and thought consuming. So, unless they are getting paid for it (some are … Will Self falls into that category), one would have to debate what motivates the ardent blogger. Shouldn’t they have just gone out for a run or cycle ride or something? 

What would actually drive someone to spend valuable time writing and airing their thoughts on any topic? What drives them to risk an avalanche of comment/critique if their particular diatribe hits the wrong button, or perhaps, a rising tide of gushing agreement from the ‘Bloggioso’ or the ‘Twitterati’ for their latest fashionable and populist masterpiece?

Some blogs are really helpful (or are they?) because they interpret and decipher some of those peer reviewed papers (which to be fair, may be a bit complex/wordy). So blogs may appear really helpful for those busy clinicians who only get limited time for reading/analysing the latest news on a topic.  

One clear attraction of blogging (for bloggers), unlike the restricted writing of peer review for instance, which requires writers to declare conflicts of interest ... is that you can say what you like … and it is clear that some bloggers ‘like what they say’.

But … is what they/we say, prone to BIAS or subject to ‘conflicts of interest’ as a result? 

To help my own decision making, I decided to gather a concoction of my own observations on some of the blog sites that may be influencing how we think and view evidence. Some bloggers may see parts themselves or their writing in one or all of the types (I did). That's not really the intention. Rather, it is for readers to see how a topic may, or may not, be spun.

I'll leave you to decide what you think ... Perhaps after a lighthearted game of 'biased BLOG bingo'.

I wrote about this in my last blog, so if you haven't already, take some time to consider the definition of confirmation bias ... 'the tendency for people to favour information that confirms their beliefs'. 

A quick look at this short YouTube clip may help.

Then consider the concept of conflict of interest which may be easy to identify in medicine for example, with concepts like 'Big Pharma' and 'Bad Pharma', which even have their own Wiki pages, but perhaps less overt in Health Sciences and related subjects. 

With those things in mind, here is my tongue in cheek personal take (from the experience of both reading and writing blogs) on a few of the types of blogger you may encounter out there … and some of the factors that may influence them ... Enjoy! 

Via https://www.flickr.com/photos/notionscapital/5379885034/

Meet some of the ‘blogger types’

1.     The altruistic/educational/hobby blogger – Blogs about a variety of topics of interest to potential readership. Evidence based, educational conduit, who likes to hear the sound of his/her voice … Keeps up to date and an open mind, avoids extremism and generally goes out of his/her way to avoid bias, May throw in some controversy for interest, but sticks to honest appraisals of the evidence. Likes a little devilish humour and for folks to read his/her blog. No commercial interests, no adverts, no shop. Altruistic, ego driven, no nonsense profile builder. Moderate use of social media (SoMe) to promote blogs. Checks blog metrics occasionally. Likes to be asked to ‘guest blog’. Secretly hopes for a trip to Hawaii to speak on his/her latest blog topic. Conflict of interest - Nil of note. Has had a book 'in the pipeline' for 15 years. 

2.     Student blogger – Students who (led by their University Professor) have entered the World of blogging, without actually knowing what they have let themselves in for. Main qualities are passion for the topic and enthusiasm. Downfall may be inexperience (blogging), naivety and failure to critique, or cover the topic from a wide and unbiased perspective. May find themselves, unwittingly at the sharp end of criticism from outraged readers. Not always prepared for this. Variable use of SoMe use, that is until they realise blog metrics contribute to their overall assessment mark. Comments are enabled … until they get thoroughly blasted by someone. Not entirely sure ‘exactly’ where Hawaii is, but would love to go. Conflict of interest? ... Actually, the main thing is ... to pass the assessment!

3.     The Snake oil seller – So enthusiastic about their particular brand of ‘snake oil’. They forgot, or chose not … to support any of their claims with even a shred of evidence. They tend to rely entirely on anecdote and personal recommendation from users of the product/idea/treatment technique. Tales of miracle cures are commonplace. Comments are moderated to include more anecdotal claims or gushing personal endorsements. Commercial interests are generally utmost on their minds and they will ALWAYS have an advert for their particular type of ‘snake oil’ on their blog. This blogger, will be targeted mercilessly by bloggers number 5 and 7, generally to no effect (because they live in their own World, or maybe Hawaii). Heavy use of SoMe. The course for this is product /idea/service is ‘brilliant’, said a delegate. Conflict of interest – Zero (there is no conflict, as their sole interest is profit). A modern day ‘medicine show’. Link directly to the 'shop' here. Entirely and unashamedly biased.

4.     Society or organisation ‘news’ blogs – Generally low-key interest/news articles for members. Designed to update folks on the latest development in the field of interest/profession. Tend to report and stick to facts, seldom court controversy and may tend to be a little bland. Media spokesperson quotes some 'evidence', but may not always be in context or entirely up to date (this will be spotted and hastily dealt with by blogger number 7). Low to moderate use of SoMe for promotion of blogs/articles. Comments commonly disabled. Bland content, seldom gives opportunity for bias. Metrics? Hawaii? Humour? Shop? ... Pardon me!?

5.     EBM proponent/Targeted attacker – Wily operator, who picks a specific (often universally disliked target) and exposes it/them and provides reams of evidence to back up his/her claims. The best of these will end up on a TV show deliver a TED talk or get a column in a broadsheet. Heavy use of SoMe to promote blogs. Commercial interests may include books, newspaper articles, TV show appearances, talks etc. Sycophants and wannabees will include them in a Tweet in the hope of a rebound (seldom works). Comments ARE enabled, and this blogger loves to argue the toss with anyone who cares to have a go and often does so with incisive humour or complex statistics. Perhaps a little obsessed and in possession of a large ego. Naturally biased towards own (often populist views) but generally and genuinely supported by the evidence. This blogger loves notoriety. Metrics are through the roof (seldom needs to check) Goes to Hawaii regularly via private jet. Conflict of interest? ‘Pah … call my booking agent, I'm busy working on my next book/TV show’.

       The rest … (Type 5b), may end up looking looking like aspiring wannabees with a particular axe to grind. These yet to be so ‘successful’ wannabee type 5's, are feverishly typing whilst waiting for ‘the phone call’ and busily fending off ad hominem attacks from ‘outraged of Tunbridge Wells’ or assorted trolls. 

6.     The evangelical blogger – Combines the friendly bonhomie of blogger type 1 with the spin of blogger 3 but has a clear underlying mission of promoting a particular product/method or school of thought. May have a track record in peer review publication, suggestive of authority, yet routinely cherry pick evidence, to support a particular view.  Entirely convinced by the sanctity of their chosen path/product. Extremist disciples, lambast non-believers or other 'churches' as unseeing heretics.

Blog comments are ALWAYS moderated and predominantly populated by devout and enthusiastic followers. Humour is not a common feature of their writing. Evidence based, but a stoic adherence to one doctrine/product/method, leads to blogs that are littered with confirmation bias and supported by cute anecdotal stories. Heavy use of SoMe for promotion. Strongly motivated by metrics and sales. Conflict of interest - You can join the latest crusade (in Hawaii) next week, which ironically coincides with their latest blog (submit HERE to apply). Merchandise shop? Click here.

7.     Frustrated, change agent blogger – This passionate and profuse blogger is entirely frustrated by the speed at which his/her profession effects change. Routinely supplies or demands ‘the evidence’, which calls for the immediate abolition of out-dated ideas, methods and products, which have been ‘shown to be ineffective’. Such vigour and attention to detail, means they may occasionally therefore, resemble the internet 'evidence police' or media watchdog. 

    Fierce belief that the only really valid evidence is the ‘gold-standard’ RCT. Particularly adept at highlighting what doesn't work ... but may omit to offer alternatives to the discarded idea/method/product ... therefore run the risk of leading his/her colleagues into an ‘evidence based’, but tool less cul-de-sac. Energetic, challenging and authoritative. Couldn’t make the conference in Hawaii, but hopes to be there next year (recently spoke in Milton Keynes/Basildon). Busy writing another blog in the mean time. Loves Twitter. Metrics matter. Big fan of type 5a.  Ubiquitous. No time for shops, but currently working on a few other conflicts of interest.

NOW it’s time brighten up the academic tedium with a game of ‘Biased BLOG Bingo’ with the blog YOU last read … errr NO, not this one, it is ENTIRELY biased to my point of view!

You can go to a presentation version of 'Biased BLOG Bingo' here 

DISCLAIMER: Bloggers take part in ‘Biased BLOG Bingo’ entirely at their own risk …
This presentation does not pertain to any bloggers called ‘Hamlin’ …or anyone else, it is merely a parody conglomeration of stereotypes. Anyway ... lighten up! 

Grid design MattLowPT

 

10 points = BINGO (start at zero) 

The higher the score the MORE biased the blog … GOOD LUCK!

1.     Is this blogger a 'snake oil seller'? (Score 6 immediately)

2.     Does the blog contain ANY credible evidence? (Deduct 1)

3.     Is the blog full of anecdote, personal experience and endorsements from users of said product/service/doctrine? (Score 3)   

4.     Is the blog balanced and offers more than one school of thought? (Deduct 2)

5.     Does the blog direct you to ALL of its sources? (Deduct 1)

6.     Does the blog direct you to just the sources it wants you to read? (Score 2)

7.     Does the blog promote ONE specific idea, method product/service? (Score 3)

8.     Does the blog recognise and report opposing views objectively? (Deduct 2)

9.     Does the blog denigrate/mock the ideas of others? (Score 2)

10.  Does the blog cherry pick evidence to support an idea, method product/service (Score 2)

11.  Are comments allowed? (Deduct 2)

12.  Are comments moderated? (Score 1)

13.  Are comments disallowed? (Score 2)

14.  Are the moderated comments predominantly congratulations from ardent ‘followers’? (Score 3)

15.  Is there a SHOP? (Score 3)

Note to BLOG readers: If your favourite blog scored 10 or more (arbitrary unscientific score) ... Just take a moment to reflect on that. There is no suggestion that blogs should not be biased, bloggers write (and sell) what they like ... BUT having a shop for instance, starts them nicely on the road to a pretty impressive BINGO score. However, it is entirely up to the reader to interpret what they see, or to recognise and identify sources of potential bias (if that is, they want to..?) just as they would, if perhaps they chanced upon a copy of the Daily Mail.

As one blogger recently said, "We are all biased" ... it is just a case of how much? So, whilst you may heartily agree with what your favourite blogger says, does or sells, it may be worth reflecting upon their potential for bias/conflict of interest AND how that affects your decision making ... and subsequent actions.

Yes, yes … I know! … I’ll be scoring my own blog later (BINGO!)

Big thanks to Will Self for his inspiration … I may include him in a Tweet (secretly hoping for a rebound ‘re-Tweet’) just before I delete my own Twitter account or become blogger number 4. 

Author: Alan J Taylor is a writer and critic who thinks about stuff and works as a Physiotherapist and University lecturer ... 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 https://twitter.com/TaylorAlanJ
... that is until, he finally deletes his account, or is 'evidence based blogged' to oblivion. 

Biased blog bingo grid design .... via @MattLowPT 

Cranial nerve testing & cervical spine risk assessment – A ‘no brainer’!

Straw poll anyone...?

Hands up manual therapists ... if you would perform a neurological examination (upper limb/lower limb/UMN), if a patient’s subjective history indicated that you should………..
GOOD, that’s pretty much 100% of you then?

Hands up ... if you would perform a cranial nerve examination if a patient’s subjective history indicated that you should…. Mmmm, I suspect that result is well below 100% (amongst physiotherapists for sure...!)

http://www.medical-artist.com/cranial-nerves.html
Medical illustrations of the cranial nerves by Joanna Culley of Medical-Artist.com

For decades, manual therapists worldwide, have talked about the importance of the D’s (dizziness, drop attacks, diplopia, dysarthria and dysphagia) and N’s (numbness, nausea and nystagmus) when taking a subjective history in patients’ suspected of having ‘vertebrobasilar insufficiency’ (VBI). 

In the same way physiotherapists in the UK, were traditionally taught to perform a thorough neurological examination in upper and lower limbs, in cases of suspected neurology or upper motor neurone dysfunction.

So why did we never really get to grips with cranial nerve examination in suspected cervico-cranial neurology? There’s no point in looking back really (though a few educationalists might shift awkwardly in their seats), the plain stark fact is that we have been missing a trick! The D’s and N’s we diligently worried so much about, were simply subjective manifestations of cranial nerve dysfunctions linked to brain ischaemia.

Frankly, it is that simple. A well-performed CN examination may provide key information to assist in the clinical reasoning, risk assessment and triage process. That is why it appears as a prominent part of the 2012 IFOMPT International Framework for Examination of the Cervical Region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention ... A somewhat long winded name, for what is essentially a cervical spine risk assessment document.

http://tinyurl.com/bpkj2xw

 

The IFOMPT document was achieved via protracted International consensus and represents the best level of evidence we currently have. Therapists would be wise to avail themselves of the key recommendations for practice contained in the document. Some key points are mentioned below, BUT … the author advises reference to the complete document for balance.

Implications for practice

There are serious conditions, which may mimic musculoskeletal (MSK) dysfunction in the early stages of their pathological progression.

1.     Cervical arterial dysfunction

2.     Upper cervical instability

This basically means that manual therapists need to possess the tools by which they can make informed decisions about risk, from a subjective and objective perspective.

A comprehensive list of risk factors and differential diagnosis table is contained within the IFOMPT document (pp 13-14). There are also some useful case histories which help to put this into perspective (pp 15-16)

  

Clinical decision-making

Some important points are made with regard to decision making for the physical examination are also highlighted.

“Based upon the evaluation and interpretation of the data from the patient history, the physical therapist needs to decide:

·Are there any precautions to orthopaedic manual therapy OMT?

·Are there any contraindications to OMT?

·What physical tests need to be included in the physical examination?” (IFOMPT 2012)

The above are generally normal practice for most experienced manual therapists. However, the following two items, frankly should be normal practice also, but are explicit in the document.

"·What is the priority for these physical tests for this specific patient? What is the order of testing and to which tests should be completed at the first visit?

·Do the physical tests need to be adapted for this specific patient?" (adapted from IFOMPT 2012)

Implications for clinicians

Well simply, there is an International guidance document, which suggests you need to think carefully about HOW TO PROCEED with your physical examination. The clinician may be wise not to launch into a ‘routine examination’ and this has obvious medico-legal implications.

What does that mean practically?

Essentially, that clinicians should, from a detailed subjective history and sound clinical reasoning, be able to adapt their clinical examination (and order of) accordingly. This may, based on the findings of the subjective history include a consideration of upper cervical instability, high or unstable blood pressure and cervical arterial dysfunction. 

A series of possible actions are described in full, in the IFOMPT document (pp 18-21)

I will draw your attention to the specific sections on cranial nerve examination and blood pressure testing (which I cover in a separate blog), which may form part of the physical examination.

Clinical pearls

 

1.     Cranial nerve testing is an essential part of physical examination in the presence of neurovascular signs and symptoms in the cranio-cervical region

2.     Physical examination involves movement and that alone may cause neurovascular compromise

3.     Remember, this is no longer just about the vertebral artery – USE SYSTEM BASED THINKING

4.     Cases of arterial compromise have been documented (usually as medico-legal cases) linked to EXAMINATION only! 

5.     Remember, this is no longer just about just arterial dissection

6.     Clinicians should be aware of the range of arterial pathologies and their potential links to movement based therapies NOT JUST MANIPULATION!

7.     GOOD NEWS …Physiotherapists are currently World leaders in guiding practitioners toward safe, evidence based practice and risk assessment in the cervical spine

It is in your interest as a clinician (at every level) to be familiar with IFOMPT 2012

References

International Framework for Examination of the Cervical Region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention (2012) http://www.ifompt.com/site/ifompt/files/pdf/Standards%20Committee/Standards%20Committee%20Documents//IFOMPT%20Examination%20cervical%20spine%20doc%20September%202012%20definitive.pdf

Taylor AJ, Kerry R (2010) A systems based approach to risk assessement of the cervical spine prior to manual therapy. International Journal of Osteopathic Medicine 13(3):85-93

Kerry R, Taylor AJ (2009) Cervical arterial dysfunction: knowledge and reasoning for manual physical therapists. Journal of Orthopaedic and Sports Physical Therapy 39(5):378-387

Education 

Anatomy Video (Armando Hasudungan)


Cranial Nerves - functions and disorders 
 
Cranial nerves - http://prezi.com/l-chg-rsdkf5/cranial-nerves/

Physiotherapy UK Congress 2013 -  http://prezi.com/yv9w6ixyjbrn/cervical-spine-risk-assessment-rehabilitation-guidance-for-safe-effective-clinical-practice/

One minute medical school - Cranial Nerves  

Cranial Nerve OSCE examination 

Two minute CN Examination

Author

Alan J Taylor  - is a medico-legal expert witness, in the field of clinical negligence related to manual therapy and stroke.

He works as an Assistant Professor in Physiotherapy and Sports Rehabilitation & Exercise Science at the University of Nottingham. 

https://twitter.com/TaylorAlanJ