The Pre-Socratics part 7 – The Sophists

In this next text through the history of philosophy we will be looking at a controversial, but influential group. Most of the information we have about this group comes to us from the writings of Plato, who didn’t like them very much (Kenny, 2010). So this biased view is something we have to keep in mind when reading and learning about them.

This group was known as the Sophists. They were a group of well-educated men who made their living by travelling through different cities offering education on several subjects including philosophy, rhetoric, mathematics, history, geography (Kenny, 2010; Russel, 1946). However, their main focus of study was in debating and arguing (Kenny, 2010; Russel, 1946).

They were mainly active around 5th century, a time during which Democracy and democratic institutions where at the core of most things in Athenian society (Adamson, 2014; Kenny, 2010; Russel, 1946). Thus, to either obtain political power and rise in this world, or plead for yourself in court, your main tool was persuasion (Adamson, 2014; Kenny, 2010; Russel, 1946). In either situation, you would have to use words to persuade the present assembly into taking or side or turning them against your opponents (Adamson, 2014; Kenny, 2010; Russel, 1946) This lead to most of the Sophist’s clients to be young men either trying to get into a political career or to make a case in court (Adamson, 2014; Kenny, 2010; Russel, 1946). Initially, the word ‘Sophist’, meant something similar to what we mean by a ‘professor’ in present day (Russel, 1946). However, possibly with some influence of Plato, this name started having a different meaning. Presently, ‘sophistry’ (what is practiced by a ‘sophist’) is understood as meaning using argumentative tricks, such as using misleading words in sentences that sound true, but without any facts to back them up, to persuade people (Adamson, 2014; Kenny, 2010) So if you call someone a Sophist, you’re saying they use deceptive arguments on purpose to persuade people of something, independently of there being any truth behind what you’re saying (Adamson, 2014; Kenny, 2010) – basically a present-day politician.

A day to day application of Sophist relativism

Several sophists where well known throughout history, but if you had to chose one name to represent them, that would have to be Protagoras (Adamson, 2014; Kenny, 2010; Russel, 1946)

One, if not the most famous of Protagoras sayings is “Man is the measure of all things, both of things that are that they are, and of things that are not that they are not” (Adamson, 2014; Kenny, 2010; Russel, 1946). This is one of the first clear instances of a relativist epistemology (Adamson, 2014; Kenny, 2010; Russel, 1946)

Protagoras firmly believed that what is true to a particular person is true for that person. The natural conclusion to this is that everyone’s beliefs are truth, but the only form of truth that exists is a relative one (Kenny, 2010). Because of this view, Protagoras was said to have been someone who could argue equally for both sides of any question (Kenny, 2010), because he didn’t see any of the arguments being truer or better in an absolute manner, they could only be truer or better than the other in a way relative to each person (Adamson, 2014). This view that an independent, objective truth does not exist fits withing the philosophical school of scepticism, leading to the Sophists also being seen as sceptics (Kenny, 2010; Russel, 1946). A sceptic is anyone who views the truth as something very, very difficult, even impossible, to discover (Kenny, 2010). As an universal, objective idea of truth does not exist, its replacement with a relative form of truth is considered by some a form of scepticism in itself (Kenny, 2010).

Another well-know Sophist, with similar sceptical views was Gorgias, who in his work “On What is Not”, argued three conclusions (Kenny, 2010):

  1. That there is nothing.
  2. That if there is anything, it cannot be known.
  3. That if anything can be known, it cannot be communicated by one person to another.

He reached these conclusions mainly through complex plays on semantics and wording, and all have been answered throughout history by different philosophers, the first by Socrates (as told by Plato), the second by Aristotle and the third on in the XX century by Wittgenstein (Kenny, 2010). I will cover these in other texts about the respective philosophers, the first two soon, and hopefully my sense of duty will keep me going until the last. This highlights an important role that the Sophists had, despite their fancy, misleading word-play and extreme view that as there is no absolute truth, persuasion is all we have (Adamson, 2014). It was through their role as argumentative adversaries that other philosophers where pushed to reflect on the nature of reality and truth, develop and polish some of the many influential ideas they have been accredited with throughout history.

I think this beautifully illustrates the importance of dialogue with people who share viewpoints that are different or opposite to ours. Ideas can be improved through the synthesis of a thesis and its antithesis.

Illustration of the indirect role of Sophists on the great ideas of history

If we reflect on the notion of truth, science has demonstrated certain facts about our reality, such as gravity, we know that there is certain knowledge we are still very far from attaining and we can question if we ever will. After all, we humans have limitations in our ability to understand the world and are less rational than we would like to admit.

Making parallelism to my clinical practice, we have evidence that informs on fundamental rules such as anatomy and physiology, which factors have an impact on someone’s presentation and recovery, with some of these aspects being quantifiable in an objective way. However, even in the quantifiable variables, we often work within statistical intervals, and we always must adapt the evidence to the individual in front of us: a relative application of systematically ascertained facts.

On the other hand, in no way is this a justification that all options you pick have the same value behind them and that you can just do whatever you want. One thing is being aware of a degree of relativism, another whole thing is having an uncritical approach to clinical practice. This will be answered by the same argument that Democritus presented to Protagoras: this view is self-refuting because if all beliefs are true, then the belief that not every belief is true will itself also be true (Kenny, 2010).

But what do you think? Is there an absolute truth we should strive for?

Or do you think that only our subjective perception of things will matter as long as it sounds right?

If it helped you live your life in a better or more comfortable way, would you accept and defend a belief independently of the truth behind it?

I hope to see you amazing nerds in the next text,

The Physiolosopher.

References:

Adamson, P. 2014. Classical Philosophy: A history of philosophy without any gaps, Volume 1. 1st edition. Oxford University Press: Oxford.

Kenny, A. 2010. A New History of Western Philosophy: In Four Parts. Reprint Edition. Oxford University Press: Oxford.

Russel, B. 1946. History of Western Philosophy. Routledge – Taylor and Francis Group: New York.

Dealing with Humans, Dealing with Complexity

The assumption that training principles applied to pain and associated disability is yet another sign of our deep craving for defined, guiding reasoning structures – from A we progress to B, from D we regress to C etc…

It reflects our inner aversion to complexity, to subjectivity. But in reality, we are all these complex and naturally subjective beings.

You deal with humans? You deal with complexity. You deal with subjectivity. Listen and learn to make sense of them. Which is so, so much.

You have Science to keep you in touch with earthly reality. Use the best scientific evidence as a guide. And also, to define your lines. It will light the way! (Don’t you know what makes “the best available scientific evidence”? You may not have realized it, but you made a commitment to it the day you became a healthcare professional. Invest in it, you won’t regret it!)

Mix it up there and see how the whole is so much more than the sum of its parts. There you have your recipe. Reason, reflect and adjust if necessary. In one way or another. Yes, it is not straightforward. Sometimes it is also sideways and backwards. Deal with it.

 Sometimes you will “fail”. Deal with that too. If the therapeutic relationship is “right” it will not be the end of the world and you both will certainly find a new path. Which may well not be with you. Yes, you have to deal with that too. And that’s really OK.

Complexity, let it be.

J

The myth of “Text Neck”

The content of this post was originally going to be included in the text on myths surrounding back pain (link to post), however because it is a somewhat complex topic and it will take some explanation to get my point across, it ended up developing into a topic worthy of its own text.

This time I’m looking at the myth of what is called ‘Text Neck’. Our necks are another part of our spine about which we have been given a lot of warnings. All over the internet there has been the clamouring for the recognition of this supposed condition, called “text-neck”. Just google it yourself – there are over 4 billion search results like it’s a very well-established thing.

Basically, like with the rest of our spine, we are told that flexing our neck, even though flexion is a natural movement of all parts of our spine, will cause either pain, injuries, or other health problems. So, the question here is: what is the actual relationship between a flexed neck, a forward head posture in clinical terminology, and pain in our neck?

One of the biggest and most recent studies about this is a systematic review and meta-analysis by Mahmoud et al (2019). They found 15 studies appropriate for review comparing measures of head and neck posture in people with and without neck pain. Most studies were of weak or moderate methodological quality (quality with which they are designed and executed) and there were a lot of differences between how head and neck posture was measured, which can make comparisons difficult and limits how sure we can be about the conclusions (Mahmoud et al, 2019). The authors found that there is an increase in forward head posture in adults with neck pain compared to adults without pain. However, there was no relevant difference between forward head posture in adolescents and adults over 50 years of age with or without neck pain.

So what gives? As a teenager, the age when we’re told that we’re always looking down at our phones, it doesn’t matter how you hold your neck, out of a sudden when you reach adulthood your neck posture starts giving you pain but that stops when you reach 50? I don’t know about you, but if the position is the problem, then this doesn’t make sense to me. Maybe your neck posture itself is not that relevant for having pain in your neck.

Considering that other studies looking at neck posture in adolescents do not show a relationship between static head posture, your posture when you’re not moving, and neck pain the authors hypothesize that this happens due to teenagers still being able to move their necks out of that flexed position and that what causes pain in adults is the loss of that ability (Mahmoud et al, 2019). The authors also theorize that the onset of pain as adults is related to loss of neck muscle endurance and flexibility as we age (Mahmoud et al, 2019).

There is still something here that doesn’t make sense. If we do assume that neck pain is caused by loss of range of movement of our neck, and this loss comes with age, why do we again stop seeing a link between neck posture and pain in those over 50 years of age?

I hope you’re starting to see how the research around this topic is not as straightforward as some people on the internet want us to believe.

But there is also another detail that limits being able to say a certain posture causes neck pain. All the studies included by the authors in the review are cross-sectional (Mahmoud et al, 2019). This means they measure and analyse people at a single point in time and do not follow them up more over time. Because of this, this study design can’t find a relationship of causality. Who can assure us the reason they appeared with a flexed neck at that point in time wasn’t because they were in pain? Or that because they were being observed, that didn’t cause them to change how they hold their body to try to meet what they thought was the expectation of the examiners? We don’t know which one came first and this highlights the very important difference between correlation and causation.

Just because things correlate, it doesn’t mean they cause each other. Otherwise, we need to stop Nicolas Cage from doing any more films.

Maybe it’s not about your posture. The association between neck pain and the amount of time we use our phones has also been looked at by Blumenberg et al (2021) and they did find that people who spent between 3 hours or more per day using their mobiles showed an increase prevalence of neck pain, as well as pain on other parts of the back. It’s important to note that they did not measure posture at rest, while using phones, or during activities.

So maybe it’s about making sure you get your joints to move often to keep them able to do so and keeping your muscles strong so they can actually move your joints. Maybe it’s about reducing the amount of time you spend in any one given posture, be it upright or flexed, sitting or standing.

How do you do that? You do it by reducing sedentary time and increasing your general amount of physical activity. Another thing to add to the benefits of exercise

But we meet the same problem again. Even though this study by Blumenberg et al (2021) used subjects from a study called the 1993 Pelotas birth cohort, which followed people from birth to when they were 22 years old, the authors only measured neck pain and total hours of use of mobile phones on the 22 years follow-up – this is, in a single point of pain. Thus, as identified by the authors, this data can only be considered cross-sectional (Blumenberg et al, 2021). To properly understand a causal relationship, we have to actually follow up people over multiple points in time and monitor the present, or lack thereof, of certain factors and their expected consequences. This is called a longitudinal design study. Luckily for us, there are a few recent studies looking exactly into that.

First, we have a study by Gustafsson et al (2017) focused on the topic of neck pain and mobile phone use. They started by examining 7092 people and the number of daily text massages. The authors managed to follow up with 4148 of those after 1 year, and again at 5 years with 2724 people from the original group (Gustafsson et al, 2017). They found that people who already had neck pain on initial assessment and were in the group with the highest reported number of daily texts, continued to have neck pain at 1-year follow-up, however, this association disappeared at 5 years (Gustafsson et al, 2017). In people without neck pain to start with, there was no correlation between developing neck pain at 1 or 5 years with any frequency of daily text messages (Gustafsson et al, 2017). One obvious limitation of this study is that they didn’t measure neck or head posture.

More recently we have the study produced by Richards et al (2021) which used the group of 2868 participants originally followed by the Raine Study who were enrolled in 1989, at around their 18th week of gestation – yes while still in the womb – and the followed-up in regular intervals. The good thing about this study is that they actually assessed neck posture, as well as neck pain, and at two different points in time: when participants were 17 years old and again at 22 years old. Let’s quickly go through their findings. Having neck pain at 17 was associated with having neck pain at 22, independently of other factors. So if you have neck pain when you are younger, you are more likely to still have it when you are older.  But now comes the interesting part. In male participants, there did not appear to be any particular factors that strongly correlated to having or not having neck pain, but there was one such factor in females: compared with having an upright posture, having a slumped or flexed posture appears to decrease the risk of having neck pain when participants became 22 years old. So, if you’re female, having a more rounded, head forward posture will reduce your chances of having neck pain at 22 years of age, but not if you’re a male? How do we make sense of this information?

Well, maybe it indicates that your posture is not a significant factor in the development, or not, of neck pain. I hope I have been able to demonstrate that across the biggest and best-designed studies, like with back pain (link to post), we cannot find a causal relationship between our neck and head posture, nor the amount of texting we do on our phones and the risk of developing neck pain. We see that people can present with flexed postures, however, we can’t say that isn’t a consequence of pain instead of the other way around. And in some cases, a flexed posture even seems to lead to less pain.

Am I safe to say R.I.P to the myth of ‘text neck’ and ask that we please stop making up new diagnoses or diseases without sufficient data to back them up? As soon as another non-evidence-based belief is made up, it easily gets widely spread by all forms of media around us (Slater et al., 2019), contributing to people believing it is a thing when it isn’t. Misinformation is really easy to spread, particularly in a society where critical thinking often isn’t promoted or rewarded.

Don’t be afraid to flex your spine, it is made to move. And don’t be afraid to read or be on your phone, at least not due to fear of it damaging your neck. Your body is more resilient than that. But don’t forget to also be active and get some exercise in. That’s how you ensure your joints remain healthy and able to move, amongst many other benefits.

Thank you for reading through and as always, if you learned something and/or found this text interesting, please share it all over social media so you can help others learn. See you in the next one.

References:

Blumenberg, C., Wehrmeister, F. C., Barros, F. C., Flesch, B. D., Guimarães, F., Valério, I., Ferreira, L. Z., Echeverria, M., Karam, S. A., Gonçalves, H., & Menezes, A. M. B. (2021). Association of the length of time using computers and mobile devices with low back, neck and mid-back pains: findings from a birth cohort. Public Health, 195, 1–6. https://doi.org/10.1016/j.puhe.2021.04.003

Christe, G., Nzamba, J., Desarzens, L., Leuba, A., Darlow, B. and Pichonnaz, C. 2021. Physiotherapists’ attitudes and beliefs about low back pain influence their clinical decisions and advice, Musculoskeletal Science and Practice. Elsevier Ltd, 53(April), p. 102382. doi: 10.1016/j.msksp.2021.102382.

Christe, G., Pizzolato, V., Meyer, M., Nzamba, J. and Pichonnaz, C. 2021. Unhelpful beliefs and attitudes about low back pain in the general population: A cross-sectional survey. Musculoskeletal Science and Practice. Elsevier Ltd, 52(August 2020), p. 102342. doi: 10.1016/j.msksp.2021.102342.

Foster, N. E., Anema, J. R., Cherkin, D., Chou, R., Cohen, S. P., Gross, D. P., Ferreira, P. H., Fritz, J. M., Koes, B. W., Peul, W., Turner, J. A., Maher, C. G. (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions. In The Lancet (Vol. 391, Issue 10137, pp. 2368–2383). Lancet Publishing Group. https://doi.org/10.1016/S0140-6736(18)30489-6

Gustafsson, E., Thomée, S., Grimby-Ekman, A., & Hagberg, M. (2017). Texting on mobile phones and musculoskeletal disorders in young adults: A five-year cohort study. Applied Ergonomics, 58, 208–214. https://doi.org/10.1016/j.apergo.2016.06.012

Korakakis, V., O’Sullivan, K., O’Sullivan, P. B., Evagelinou, V., Sotiralis, Y., Sideris, A., Sakellariou, K., Karanasios, S., & Giakas, G. (2019). Physiotherapist perceptions of optimal sitting and standing posture. Musculoskeletal Science and Practice, 39, 24–31. https://doi.org/10.1016/j.msksp.2018.11.004

Laird, R. A., Kent, P., & Keating, J. L. (2012). Modifying patterns of movement in people with low back pain -does it help? A systematic review. In BMC Musculoskeletal Disorders (Vol. 13). BioMed Central Ltd. https://doi.org/10.1186/1471-2474-13-169

Lima, M., Ferreira, A. S., Reis, F. J. J., Paes, V., & Meziat-Filho, N. (2018). Chronic low back pain and back muscle activity during functional tasks. Gait and Posture, 61, 250–256. https://doi.org/10.1016/j.gaitpost.2018.01.021

Mahmoud, N. F., Hassan, K. A., Abdelmajeed, S. F., Moustafa, I. M., & Silva, A. G. (2019). The Relationship Between Forward Head Posture and Neck Pain: a Systematic Review and Meta-Analysis. In Current Reviews in Musculoskeletal Medicine (Vol. 12, Issue 4, pp. 562–577). Springer. https://doi.org/10.1007/s12178-019-09594-y

Richards, K. v., Beales, D. J., Smith, A. L., O’sullivan, P. B., & Straker, L. M. (2021). Is neck posture subgroup in late adolescence a risk factor for persistent neck pain in young adults? a prospective study. Physical Therapy, 101(3). https://doi.org/10.1093/ptj/pzab007

Sheha, E. D., Steinhaus, M. E., Kim, H. J., Cunningham, M. E., Fragomen, A. T., & Rozbruch, S. R. (2018). Leg-Length Discrepancy, Functional Scoliosis, and Low Back Pain. In JBJS reviews (Vol. 6, Issue 8, p. e6). NLM (Medline). https://doi.org/10.2106/JBJS.RVW.17.00148

Slater, D., Korakakis, V., O’Sullivan, P., Nolan, D., & O’Sullivan, K. (2019). “Sit up straight”: Time to Re-evaluate. In Journal of Orthopaedic and Sports Physical Therapy (Vol. 49, Issue 8, pp. 562–564). Movement Science Media. https://doi.org/10.2519/jospt.2019.0610

The Pre-Socratics part 6 – Caring about Health

Welcome to another text where we continue our journey through the philosophers who developed the ideas that inspired most of our own at present. Today we are going to explore a name that may not be as obscure as the ones before: Hippocrates.

Giving some justification to my personal interest in philosophy, in ancient Greece, philosophy and medicine were tightly bound, as it happened with many other fields of present-day science, both having an influence on each other (Adamson, 2014). Hippocrates is originally from an island of the coast of Ionia (where the Milesian school was) name Kos. We don’t have full certainty, but the available evidence suggests that Hippocrates is younger than Socrates and a likely contemporary of Plato and possibly Aristotle, placing him between late 4th century BC and early 3rd century BC with Hippocrates’ works being influential to them (Adamson, 2014).

Hippocrates is famously hailed as the father of medicine (Adamson, 2014; Kleisiaris et al., 2014) for both his great achievements in ancient Greek medicine as well as being credited with developing a lot of the ideas that still function as the philosophical core of modern medicine. One of his most famous, and still influential to present day, ideas is what is considered the fundamental precept of medical ethics: “Primum non nocere”, “First of all, do no harm” (Adamson, 2014). This idea first originated in one of Hippocrates’ texts, the Epidemics, which interestingly analysed the disease outbreaks at the time (Adamson, 2014). This text is one of many that composes a whole body of texts commonly known as the Hippocratic Corpus. These texts would cover a range of topics ranging from different diseases, drugs and medical ethics even (Adamson, 2014).

Within its records we find that when the Greeks first started organising the Olympic Games, some people started specialising in the care of athlete’s health and the prevention of injuries, under the title of “paidotrivai”(Kleisiaris et al., 2014), being the first to use massage oils, specifically olive oil, with the aim of warming up athletes and avoid sport injuries (Kleisiaris et al., 2014). I consider the fact that a lot of this practices still prevail not as a sign of the genius of Hippocratic medicine, but of how outdated some of present-day practices are. In the Hippocratic corpus we also find the first descriptions of treatment of traumatic wounds, fractures and surgeries such as amputation to stop gangrene, which were used until at least the Middle Ages (Kleisiaris et al., 2014).

Despite bearing his name, not all these texts were written by Hippocrates, but also by other physicians who learned from him or followed in his teachings (Adamson, 2014). There were forms of archaic medicine before this, but the Hippocratic corpus is where we found the earliest surviving systematic texts on medicine (Adamson, 2014). Another common trend between medicine and philosophy at the time was the separation from religious practices and beliefs, instead seeking to have a basis on rationality and science (Adamson, 2014; Kleisiaris et al., 2014). Thus, the underlying philosophy of Hippocratic medicine is that medicine should be seen as a scientific discipline that bases itself on the natural sciences when diagnosing, preventing and treating diseases (Kleisiaris et al., 2014). However, this separation was not complete. While the overall belief at the time was that diseases were caused by the gods, in the Hippocratic corpus it is stated if diseases were in any way sacred, was because they were caused by forces of nature that were themselves sacred, such as the sun or wind (Adamson, 2014). The idea that gods would just randomly curse individual mortals was argued against, but there was still room for belief in gods and the divine (Adamson, 2014).

Still, Hippocrates contributed to the first steps of modern medicine, arguing that diagnosis, prognosis and treatment should be based on detailed observation, reason and the accumulation of observed experience (Kleisiaris et al., 2014). In other words, medicine should be based on knowledge obtained from the available empirical evidence (Kleisiaris et al., 2014).

However, the bigger influence to Hippocratic medicine came from the philosophical and scientific theories of the pre-socratics, such as Empedocle’s theory of the four elements that I covered previously. You should read the previous text for further details on Empedocle’s theory, but put simply, everything in the universe is made of four elements: air, earth, fire and water (Adamson, 2014). This will thus include human bodies, leading to our link between this theory and medicine. If we got ill, it was because the elements in our body are not in the proportion they should (Adamson, 2014; Kleisiaris et al., 2014). Also utilising the same theory of balancing the four elements and how hot, cold, dry or wet our body to explain how they worked, Hippocratic doctors would already utilise certain drugs as part of their treatment (Adamson, 2014).

This type of theory may seem non-sensical to us, but it’s not that far-fetched when you consider the observations that could be made at the time such as being quite common to develop a fever when you’re ill or that when people die they stop breathing (Adamson, 2014). Still, it was insisted by the Hippocratic doctors that the practice of medicine isn’t as simple as memorizing a few theoretical principles and applying these automatically, being more akin to a form of art (Adamson, 2014). I personally don’t like this phrasing without proper contextualisation, as it opens the door for a lot of esoteric quackery to be accepted into medicine and healthcare. What is meant by art here is a non-rigid, holistic approach to medicine, one where we treat the whole body, not just the symptomatic body part, and we consider the individual circumstances of each patient (Adamson, 2014). Still relating to this theory and within the writings found in the Hippocratic corpus, was the first mention of the four-humour theory (Adamson, 2014; Kleisiaris et al., 2014). According to this theory, for us to be and remain healthy, there has again to be balanced proportions within our body, not of the elements, but of certain types of fluids called the bodily humours: blood, phlegm, yellow bile, and black bile (Adamson, 2014). Based on this, Hippocratic doctors had also started using bloodletting and cupping (Adamson, 2014). They would, however, advise against using this often and displayed an overall reluctant stance against any type of “invasive” procedures (Adamson, 2014). Interestingly, even though I like to think no one with a minimal level of knowledge of biology and ability to think critically nowadays would take the four-humour seriously, a lot of these interventions are still greatly used and advertised presently even amongst healthcare providers. This is not due to shown effectiveness in quality critical trials, so I do wonder what makes people still commonly utilise outdated practices such as cupping if the theory explaining its acting mechanism is not supported by biology? Why have certain sectors and agents of healthcare failed to move from 400BC? I’ll explore this more below when I highlight what I consider to a very pertinent text from the Hippocratic corpus. But first I want to discuss what was actually the principal and most common of the treatments prescribed by Hippocratic doctors: the right diet and amount of exercise (Adamson, 2014; Kleisiaris et al., 2014).

In general, Hippocratic doctors were firm supporters of preventative medicine, (Adamson, 2014) and argued the importance of environmental causes and natural treatments of diseases, the importance of psychological factors, nutrition and lifestyle, independence of mind, body and spirit, and the need for the harmony between the individual and the social and natural environment as both causes and treatment of health problems (Kleisiaris et al., 2014). Ancient Greeks in general believed that mental and physical health were connected, with the phrase “healthy mind in a healthy body” came from this belief (Kleisiaris et al., 2014). In this sense, it appears they were ahead of us in their understanding of health, as amongst the general public and health care practitioners, the importance of psychosocial factors remains underrecognized (Haslam et al., 2018). This shows a view that aimed to treat the individual as whole, addressing the psychosomatic entity that is a disease, instead of treating symptoms (Kleisiaris et al., 2014). In line with this, the assessment performed by Hippocratic doctors included noting geographical location, climate, age, gender, habits, diet, rational moods swings, duration of sleep, appetite, thirst, nausea, location and severity of pain, chills, coughing, sneezing, and menstrual changes (Kleisiaris et al., 2014). A lot of these details remain part of modern medical history taking. Based on this information and examination of symptoms, Hippocratic doctors would diagnose patients and treat them, establishing the basis of medicine for the present day (Kleisiaris et al., 2014). Not only this, but the Hippocratic corpus also introduced many of the medical terms still used today such as symptom, diagnosis, therapy, trauma, sepsis, diabetes, arthritis, cancer, coma, paralysis, epilepsy, among others (Kleisiaris et al., 2014).

One particular text in the corpus I want to highlight is the famous Oath (Adamson, 2014) which focuses on professional integrity, benevolence and human dignity (Kleisiaris et al., 2014) In particular, I want to highlight some of the points from the Modern version of the Hippocratic Oath, that were already present in Hippocrates’ arguments: (Harris and Buchbinder, 2021):

  • Medicine should be based on and respect the evidence produced through the scientific method.
  • Overtreatment and overdiagnosis should be avoided.
  • Understanding of natural history of symptoms and reassurance of patients takes precedence over medical interventions.
  • Doctors should be honest about the actual limited effectiveness of certain medical interventions.
  • Treatment should be based on individual patient circumstances and presentation as opposed to scans and other investigations.
  • The focus on medicine should be on public health measures focused on healthy lifestyle as opposed to more passive and sometimes invasive interventions.

I find it astonishing that despite these values being present since Hippocrates and doctors the oath being considered the code of conduct for medical doctors even in present day, a lot of the current problems in healthcare stem from these ideals not being adhered to. Some examples are unnecessary imaging, opioids, and surgery for non-serious back pain; arthroscopic surgery for knee osteoarthritis; subacromial decompression surgery for shoulder pain; platelet-rich plasma injections for tendinopathies and osteoarthritis. (Harris and Buchbinder, 2021). I will also point the finger at my own profession of physiotherapy and highlight other problematic examples such as offering “diagnoses” that are no more than natural anatomical variations, also overestimating the effectiveness of interventions such as massaging, manipulating and sticking needles in people’s bodies, disregard for patients’s individual environment and circumstances. Why do healthcare professionals behave in this way? Curiously because of the following trait that they appear to have in common with many practitioners of alternative “medicines”: reluctance to admit that they don’t know and seeing not testing or treating a patient as a failure to care (Harris and Buchbinder, 2021).

This, however, is not entirely their fault. Just like patients are part of an environment that has an effect in their health, so do healthcare professionals work in a system that propagates the expectation from both clinicians and patients that there is always a need to exclude or provide a diagnosis or a treatment, where diagnoses and diseases are created to treat measured values or other findings independently of how these correlate to symptoms, and treatments “need” to be tried instead of choosing advice, reassurance and simply waiting while monitoring (Harris and Buchbinder, 2021).

This is way I think we need to again create a better link between philosophy and healthcare. I’ll go even as far as arguing that we need to bring back philosophy into most aspects of our quotidian. We have so much to learn from exploring how ideas came to be over the ages. I hope this journey through the philosophers of history has started to make you aware of this. I will continue this journey at another time. Thank you for reading through and as always, if you learned something and/or found this text interesting, please share it all over social media so you can help others learn. See you in the next one.

References:

Adamson, P. 2014. Classical Philosophy: A history of philosophy without any gaps, Volume 1. 1st edition. Oxford University Press: Oxford.

Harris, I. A., & Buchbinder, R. (2021). How doctors are betraying the Hippocratic oath. The BMJ, 375. https://doi.org/10.1136/bmj.n2807

Haslam, S. A., McMahon, C., Cruwys, T., Haslam, C., Jetten, J., & Steffens, N. K. (2018). Social cure, what social cure? The propensity to underestimate the importance of social factors for health. Social Science and Medicine, 198, 14–21. https://doi.org/10.1016/j.socscimed.2017.12.020

Kleisiaris, C. F., Sfakianakis, C., & Papathanasiou, I. v. (2014). Health care practices in ancient Greece: The Hippocratic ideal. In J Med Ethics Hist Med (Vol. 7).

Introduction to Evidence-Based Practice part 2: Framework for Understanding

This text is the second part of my attempt at introducing you to evidence-based practice and making this process generally better understood by everyone. If you haven’t already, check part 1 before reading this one to understand why we can’t just rely on our own thought processes to gather knowledge about the world and make decisions in healthcare. Our minds, even in their most rational moments, are flawed things – and this statement is devoid of any moral judgment. It’s just how we are, myself included. 

Throughout the centuries, a lot of smart people have been thinking about this problem of overcoming the limitations of our cognitive process and better understand both the world and ourselves, as well as help us decide on the best way of doing things. Let’s have a look at what has been done. 

Evidence-based medicine is not something just for academics or scholars, as from the beginning it was created with the aim of educating front-line clinicians (Djulbegovic and Guyatt, 2017). This is reinforced by the notion that one of the characteristics that define a group of people as a profession is the opportunity to develop knowledge through research activity that will then be utilised to inform said practice (Finch, 2007). 

Part of the reason why Evidence-based medicine was created was the recognition, which it itself does, that understanding research, its results, and applying it to individuals who often don’t share the same characteristics as those selected for studies is quite difficult (Djulbegovic and Guyatt, 2017). The best way of talking about a difficult topic is to start by defining what we are actually talking about. In part 1 I presented the initial definition of Evidence-based medicine proposed by Guyatt et al (1992), which I recognise may point us towards what not to do more than what we should be doing in order to have an evidence-based practice. But worry not, as its definition has been clarified over time and since 1996 is described as integrating the best available research evidence, the individual clinician’s experience and expertise, as well as the patient’s values, preferences and circumstances (Sacket et al, 1996; Finch, 2007; Meira, 2020).

But let’s not stop here, let’s define what is meant by each of these three elements. The best available research evidence means looking at all available evidence relating to our clinical question in a systematic manner (Meira, 2020). This sounds very laborious, but the reason it needs to be done is that not all pieces of evidence obtained from research have the same quality and presently it is very easy to find a research article that supports or favours our preferences (Djulbegovic and Guyatt, 2017; Meira, 2020). It is also arguable that the higher the quality of the evidence, the closer to the truth are our conclusions regarding diagnostics, prognosis, and effects of interventions (Djulbegovic and Guyatt, 2017). Thus, we come to the first epistemological principle of Evidence-based medicine: not all evidence is created equal and clinical practice should be based on the best available evidence (Djulbegovic and Guyatt, 2017). 

Previously, this was associated with the methodological design of the study, with randomised controlled trials being considered the best studies and everything else, was considered to be below that type of design. But science and research aren’t perfect, as many critics are ready to point out. However, this is not in itself an argument to discredit the use of the scientific method or evidence-based practice. Interestingly, these critics forget to mention that these flaws have been identified by the same researchers who partake in the scientific method (Finch, 2007; Djulbegovic and Guyatt, 2017). 

At present, a study’s quality is considered based on how well the study design fits the question being asked and how well it fits the particular clinical setting and patient circumstances, as well as the quality, not category, of the methodological design of said study (Finch, 2007; Djulbegovic and Guyatt, 2017). In order to help critically and systematically assess the quality of a research paper, several tools have been developed such as the Grades of Recommendation Assessment, Development and Evaluation (GRADE) system published in 2004 (Oxman, 2004), the Preferred Reporting Items for Systematic reviews and Meta-Analyses (Liberati et al, 2009) and the PROSPERO international prospective register of systematic reviews (Booth et al, 2012). 

Next, clinical expertise refers to being skilled in critical thinking. Clinical expertise is more complex than supporting a claim by saying “in my professional experience”. It is a nuanced process that requires a synthesis of possible contradictions during moments of uncertainty, instead of just saying something is ‘right’ or ‘wrong’ (Meira, 2020). Even though scientific literature cannot deny what we see in clinic, it can however refute our explanations of those events. In other words, even if something appears to work during practice, after being scrutinized through current evidence, we may find that neither our explanation or the perceived benefit of the treatment approach are accurate (Meira, 2020). This is exactly why science doesn’t work by results of individual studies or observations but from the knowledge obtained from critically analyzing the totality of existing research on a topic (Djulbegovic and Guyatt, 2017). Following this thought process, we have arrived at the second epistemological principle of Evidence-based medicine: the quest for truth is best accomplished by analyzing the totality of the evidence, instead of just selecting evidence that favours a particular argument (Djulbegovic and Guyatt, 2017). 

Lastly, but still highly important, we have patients’ preferences and circumstances. The patient is always the final decision maker (Meira, 2020). I’m going to confess this is a view I have not always shared. Throughout my training I was taught the idea that clinicians are the experts with all the knowledge, so during the beginning of my career, I often would consider that a patient’s opinion was not worth evaluating when deciding on care. Patients don’t have any clinical knowledge, how could their opinion be useful in healthcare? I’m sharing this to show that I’m not above making mistakes and continue to make an effort to learn more and improve – this website and these texts are part of that effort. 

We need to consider the patient’s circumstances and preferences because the first may be a barrier to the direct application of research findings, as the patient’s presentation may not match the sample used in clinical studies, and neither we nor the patient may have the same equipment or time resources as the ones used in the literature (Djulbegovic and Guyatt, 2017; Meira, 2020); the latter also needs consideration as patients will be the ones living with the consequences, positive or negative, of their decision (Djulbegovic and Guyatt, 2017; Meira, 2020) and sometimes the evidence is still not fully clear in what interventions are more beneficial, not giving us a clear path to follow, so we may follow what the patient thinks will be more suitable for them and increase both adherence and develop the therapeutic relationship. This can be neatly summarised into the third epistemological principle of Evidence-based medicine: we need to consider patients’ values and preferences during clinical decision-making. Evidence is necessary, but not sufficient for effective decision making, which has to consider the relevant consequences to the patient within their context and circumstances (Djulbegovic and Guyatt, 2017). 

We cannot say we are evidence-based clinicians if we don’t follow these principles and integrate these elements into our daily practice. However, it is important to point out that although the best available evidence, clinical expertise, and patient circumstances and preferences are all necessary for evidence-based practice, they don’t all have necessarily the same weight in informing clinical decisions. In the past some authors and clinicians have described these three elements as “three legs of a stool”, which has led to mistakes such a citation that supports our bias being confused for available evidence, choosing an intervention that suits our bias being for clinical expertise and the patient agreeing to that intervention that we prefer and is supported by a single article being confused for integrated patient’s values into decision making (Meira, 2020). 

Instead, Evidence-based medicine is better seen as a funnel, a framework that guides our practice by narrowing the highest quality evidence, which is then through clinical expertise further narrowed and explained to the patient, who then based on their preferences and circumstances will further narrow down the available options into a plan that suits them. This framework has been described and illustrated by Meira (2020) in an excellent way: 

Also worth notice, is that the steps of this framework can only be taken in the narrowing direction. In other words, it is not evidence-based to select an intervention because it fits the clinician or patient preference if it is not supported by the totality of the best quality evidence. By practicing in this way, we risk selecting interventions that have not shown to be effective, wasting both the patient’s time and money, as well as possibly endangering the safety and well-being of the patient. 

Considering this, it is arguable that developing our research literacy is as important as developing any other knowledge or skill related to patient assessment (Finch, 2007). Thus, universities should prioritize that a significant focus of their curricula is guiding students towards competence in understanding research methodology, being able to perform critical evaluation of evidence, and systematically applying it to their clinical setting (Finch, 2007). 

This text is in no way an exhaustive description or explanation of what is Evidence-based medicine and how it is informed by the scientific process. However, I hope it has helped you understand that Evidence-based medicine is not a dogmatic faith-like cult, but instead a critical and systematic process that aims at challenging our own bias through a pursuit of a humanely achievable approximation of the truth that promotes patient safety and better healthcare outcomes. 

Don’t forget to share if you found this text interesting and comment if you disagree or have questions about any part of it. Hopefully, I’ll see you in the next text. 

References: 

Booth, A., Clarke, M., Dooley, G., Ghersi, D., Moher, D., Petticrew, M., & Stewart, L. (2012). The nuts and bolts of PROSPERO: An international prospective register of systematic reviews. Systematic Reviews, 1(1). https://doi.org/10.1186/2046-4053-1-2 

Djulbegovic, B., & Guyatt, G. H. (2017). Progress in evidence-based medicine: a quarter century on. In The Lancet (Vol. 390, Issue 10092, pp. 415–423). Lancet Publishing Group. https://doi.org/10.1016/S0140-6736(16)31592-6 

Finch, P. M. (2007). The evidence funnel: Highlighting the importance of research literacy in the delivery of evidence informed complementary health care. Journal of Bodywork and Movement Therapies, 11(1), 78–81. https://doi.org/10.1016/j.jbmt.2006.09.001 

Guyatt, G., Cairns, J., Churchill, D., Cook, D., Haynes, B., Hirsh, J., Irvine, J., Levine, M., Levine, M., Nishikawa, J., Sackett, D., Brill-Edwards, P., Gerstein, H., GIbson, J., Jaeschke, R., Kerigan, A., Nevile, A., Panju, A., Detsky, A., … Tugwell, P. (1992). Evidence-Based Medicine – A New Approach to Teaching the Practice of Medicine. JAMA, 268(17), 2420–2425. 

Liberati, A., Altman, D. G., Tetzlaff, J., Mulrow, C., Gøtzsche, P. C., Ioannidis, J. P. A., Clarke, M., Devereaux, P. J., Kleijnen, J., & Moher, D. (2009). The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Journal of Clinical Epidemiology, 62(10), e1–e34. https://doi.org/10.1016/j.jclinepi.2009.06.006 

Meira, E. (2020). Understanding evidence-based medicine using a funnel analogy. Society for Transparency, Openness and Replication in Kinesiology. https://doi.org/10.31236/osf.io/kr6aq 

Oxman, A. D. (2004). Grading quality of evidence and strength of recommendations. In British Medical Journal (Vol. 328, Issue 7454, pp. 1490–1494). https://doi.org/10.1136/bmj.328.7454.1490 

Sacket, D. L., Rosenberd, W. M., Gray, J. A. M., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: what it is and what it isn’t. BMJ, 312, 71–72. 

Introduction to Evidence-Based Practice part 1: Flawed Opinions

Hi everyone. This text opens up a new realm of topics compared to what I’ve written about so far. It is still very relevant to and needed in physiotherapy, and I also can’t fully separate these topics from philosophy. I will be attempting to explain what is evidence-based practice, why it is needed in healthcare, and how its underpinning philosophy can even be helpful in our day-to-day. 

I wasn’t planning to write this text now. However, there is a greater need for us to examine evidence-based practice than I thought. I was also assuming while writing my previous texts, that it was likely people reading them would understand why I’ve been putting references throughout the text. Maybe I was assuming more than I should and a good first step when arguing for anything is making sure that everyone involved in that discussion has the same understanding of the concepts involved. 

Looking at my own profession – because part of my personal philosophy is that being critical should start with being critical of ourselves – I’ve recently become more aware that even within a profession that is supposed to base its practice on science, like what is expected from medicine and other health professions, this is still mostly not the case. The underlying reasons for this are complex, but they start at the basic level of a lack of understanding of what the scientific method even is and why it is still the best form of generating knowledge that we have. 

I’ve become aware of this gap of knowledge both anecdotally, through seeing what people I know and peers of mine share on social media – I need to mention that Covid seems to have greatly highlighted the lack of understanding of science in general – and how they argue certain concepts; but this can also be seen in the scientific literature, which shows that for the treatment and management of musculoskeletal conditions, close to 50% of physiotherapists do not follow evidence based-guidelines (Zadro, O’Keeffe & Maher, 2019). Close to 50% of people in a modern, healthcare profession, often working in hospitals and integrated into national health services, do not follow evidence-based guidelines in their daily practice! 

This will be the first part of my introduction to evidence-based practice. But to understand why we need to be concerned with this, we first need to look at what is evidence-based practice.  

Initially coined in 1992 by Gordon Guyatt and ‘The Evidence-Based Medicine Working Group’ he was chairing at the time (Guyatt et al, 1992), at the time named ‘Evidence-Based Medicine’ specifically, was described as a paradigm that “…de-emphasizes intuition, unsystematic clinical experience, pathophysiologic rationale as sufficient grounds for clinical decision making and stresses the examination of evidence from clinical research.”  

This epistemological conflict isn’t something new, as at least since the time of Hippocrates (which I will be covering in a post in the near future), there has been an ongoing debate between un-verified personal clinical experience and rigorous systematic research (Djulbegovic, Guyatt, 2017). 

Some of you might be by now asking “What is the problem of basing my decisions on my personal experience? It has served me well in life so far. You’re just a nerd who wants to feel superior by bringing others down.” 

All I ask is for a chance to explain, as to understand why we should do something differently, we first must recognise what is the problem with the way we currently do that something. 

Throughout our day-to-day, we have to make a lot of decisions and some decisions are harder than others. We can consider this difficulty to go up when we have to make a decision about someone else’s health with our job potentially being on the line with the outcome of that decision – a clinical decision. When you work in healthcare, you have to do a lot of these decisions, in addition to our normal day-to-day decisions. So it makes sense we try to make these as quickly as we can – everyone has got a lot to do during their day! 

The way our mind generally works around decision making and behavioural choice has been theorised by cognitive scientists as having two types of processes running simultaneously (Evans, 2008; Phua, Fams and Tan, 2013; Houlihan, 2018; Monteiro et al, 2020), which were first described by Wason and Evans (1974). These processes are often known as Type 1 and Type 2 (Monteiro et al, 2020), and have the following characteristics: 

  • Type 1 processes do not require working memory, are autonomous and often described as unconscious and faster (Evans, 2008; Evans and Stanovich, 2013; Phua, Fams and Tan, 2013; Houlihan, 2018; Monteiro et al, 2020). 
  • Type 2 processes require working memory, involve mental simulation and are often describes as conscious and slower (Evans, 2008; Evans and Stanovich, 2013; Phua, Fams and Tan, 2013; Houlihan, 2018; Monteiro et al, 2020). 

Both processes are very helpful in our everyday personal and professional life. It is described in the literature that more experienced clinicians tend to utilise Type 1 processes for pattern recognition, based on previous experiences and intuition (Norman, 2009; Phua, Fams and Tan, 2013; Monteiro 2020), changing to Type 2 processes if they come upon something they haven’t encountered previously (Norman, 2009; Phua, Fams and Tan, 2013; Monteiro 2020). This is where clinical experience can have value. 

However, as we know, none of us is perfect, or as rational and objective as we would like to think we are, leading to all of us committing errors, particularly in such a complex context as healthcare (Phua, Fams, and Tan, 2013; Richardson, 2014; Saposnik et al, 2016). This is because things like our prior beliefs and our emotions influence both how we perceive external information as well as our conscious and unconscious reasoning processes (Phua, Fams, and Tan, 2013; Houlihan, 2018). 

In addition to this, in order to make decisions quicker within our limited ability to process information, we often take mental shortcuts for problem-solving, formally called Heuristics (Richardson, 2014; Saposnik et al, 2016; Monteiro et al, 2020). When these mental shortcuts are overused, they lead to errors in reasoning, called Cognitive Bias (Phua, Fams, and Tan, 2013). Heuristics and biases were first described by Kanheman and Tversky (1974), when through a series of studies on psychology undergraduates they demonstrated how heuristics were often used and how they could lead to mistakes. It is important to highlight that both Type 1 and Type 2 processes can lead to errors and bias (Phua, Fams and Tan, 2013; Monteiro et al, 2020) 

Here are some examples: 

  • Availability bias: we are more likely to remember or recall things that are not of the norm, for example a patient that went really badly or really well, making us think those type of events happen more often then they do (Kanheman and Tversky, 1974; Norman, 2009; Monteiro et al, 2020) 
  • Confirmation bias: We tend to, even unconsciously, seek and pay more attention to data that confirms our hypothesis, sometimes ignoring opposing data (Kanheman and Tversky, 1974; Norman, 2009; Monteiro et al, 2020) 
  • Hindsight bias: when we already know the outcome of an event, that will influence our understanding of how that outcome came to be, making things seem connected when they actually weren’t or miss a crucial the effect of an event leading to that outcome (Kanheman and Tversky, 1974; Monteiro et al, 2020) 

Just to reinforce how fallible and irrational our minds can be, here is an illustration of all the cognitive biases identified until today.

However, the limitations of our minds and cognitive processes don’t end here. It is not simply about the way we think about topics. It also appears that the knowledge we have or don’t have, as a basis to think about, will also influence our decisions with a lack of knowledge also being pointed to in research as a source of errors (Phua, Fams, and Tan, 2013; Monteiro et al, 2020). This helps understand why neither identifying biases nor applying debiasing strategies have shown to lead to a reduction in errors in making clinical diagnosis (Monteiro et al, 2020). It is also very difficult to differentiate which errors come from a lack of knowledge and which ones come from mistakes in our thinking (Norman, 2009). 

I’m not going to go into a lot more detail about this as we already started talking about things such as psychology, neurosciences, and meta-cognition, with me not being an expert in any of these and an in-depth exploration of these topics, despite sounding incredibly interesting, may not be required to get across the point I want to make in this first part: our perception of the world and what happens in it is very flawed and not warrants some suspicion when thinking about complex topics – such as clinical practice. And this includes my own perceptions. 

Thus, opinion, be it my own, yours, or anyone’s, without being supported by facts or critically analysed information, is not a trustworthy source to make affirmations about the world, particularly about health constructs, diagnostic tests, or the benefits of clinical treatments. 

Thinking that we can understand the complex world we live in based on just our own experience, absent of any systematic criticism is nothing short of overconfidence in our own knowledge and capabilities. And let me tell you that overconfidence has been highlighted as one of the more common biases as well as the one leading to more diagnostic errors in healthcare (Phua, Fams, and Tan, 2013; Saposnik et al, 2016). 

We need something to make us double-check our own conclusions, some type of system that executes a criticism of our reasoning and juxtaposes it to both opposing reasoning and experiences, as well as provides us quality knowledge from data gathered from the perceivable elements of the universe. 

In the next part, I will explain that such a system has already been created and continues to alter its way of working while maintaining a dynamic core philosophy of trying to reduce errors as much as possible: evidence-based practice.

Thank you for reading and until the next one.

References: 

Djulbegovic, B., & Guyatt, G. H. (2017). Progress in evidence-based medicine: a quarter century on. In The Lancet (Vol. 390, Issue 10092, pp. 415–423). Lancet Publishing Group. https://doi.org/10.1016/S0140-6736(16)31592-6 

Evans, J. S. B. T. (2008). Dual-processing accounts of reasoning, judgment, and social cognition. Annual Review of Psychology, 59, 255–278. https://doi.org/10.1146/annurev.psych.59.103006.093629 

Evans, J. S. B. T., & Stanovich, K. E. (2013). Dual-Process Theories of Higher Cognition: Advancing the Debate. Perspectives on Psychological Science, 8(3), 223–241. https://doi.org/10.1177/1745691612460685 

Guyatt, G., Cairns, J., Churchill, D., Cook, D., Haynes, B., Hirsh, J., Irvine, J., Levine, M., Levine, M., Nishikawa, J., Sackett, D., Brill-Edwards, P., Gerstein, H., GIbson, J., Jaeschke, R., Kerigan, A., Nevile, A., Panju, A., Detsky, A., … Tugwell, P. (1992). Evidence-Based Medicine – A New Approach to Teaching the Practice of Medicine. JAMA, 268(17), 2420–2425. 

Houlihan, S. (2018). Dual-process models of health-related behaviour and cognition: a review of theory. In Public Health (Vol. 156, pp. 52–59). Elsevier B.V. https://doi.org/10.1016/j.puhe.2017.11.002 

Monteiro, S., Sherbino, J., Sibbald, M., & Norman, G. (2020). Critical thinking, biases and dual processing: The enduring myth of generalisable skills. Medical Education, 54(1), 66–73. https://doi.org/10.1111/medu.13872 

Phua, D. H., Fams, E., & Tan, N. C. (2013). Cognitive Aspect of Diagnostic Errors (Vol. 42, Issue 1). 

Richardson, L. G. (2014). Awareness of Heuristics in Clinical Decision Making. Clinical Scholars Review, 7(1), 16–23. https://doi.org/10.1891/1939-2095.7.1.16 

Sacket, D. L., Rosenberd, W. M., Gray, J. A. M., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: what it is and what it isn’t. BMJ, 312, 71–72. 

Saposnik, G., Redelmeier, D., Ruff, C. C., & Tobler, P. N. (2016). Cognitive biases associated with medical decisions: a systematic review. BMC Medical Informatics and Decision Making, 16(1), 1–14. https://doi.org/10.1186/s12911-016-0377-1 

Tversky, A., & Kahneman, D. (1974). Judgement under Uncertainty – Heuristics and Biases. Science, 185(4157), 1124–1131. 

Wason, P. C., & Evans, T. (1974). Dual processes in reasoning?*. Cognition, 3(2), 141–154. 

Zadro, J., O’Keeffe, M., & Maher, C. (2019). Do physical therapists follow evidence-based guidelines when managing musculoskeletal conditions? Systematic review. In BMJ Open (Vol. 9, Issue 10). BMJ Publishing Group. https://doi.org/10.1136/bmjopen-2019-032329 

The Pre-Socratics part 5 – Love and Strife make the world go around

Today I will be writing about a very interesting, even legendary, pre-socratic philosopher: Empedocles. He was from Acragas, in the South of Sicily, and considered himself to be a god (Adamson, 2014; Kenny, 2010; Russell, 1946). This, of course, lead to tales of him being able to perform miracles such as controlling the winds or reviving a woman who had supposedly been dead (Adamson, 2014; Russell, 1946). 

However, despite all the fairy tales surrounding his life, he made significant contributions to philosophy and science, the most important of which can be considered to be the discovery of air as its own substance (Russell, 1946). This came through observing that when a bucket, or something similar, is put upside down into water, the water does not fill up the object (Russell, 1946). This is something you can even try for yourself: go grab a glass, put it upside-down into water, and check if any water gets inside. You can’t say I’ve never provided you with a DIY scientific experiment you can do at home. 

Pirates of the Caribbean and all it’s characters and intellectual property are own and distributed by Walt Disney Pictures and Walt Disney Studios Motion Pictures

Empedocles is also said to have discovered an example of centrifugal force by noticing that water will not come out from inside a cup if the latter is tied to the end of a string and spun around (Russell, 1946). In addition to this, he theorized that the moon shone through reflected light, but that this was also true for the sun, and that light travels too fast for us to see but that it does take time for it to travel (Russell, 1946). 

To add to this amazing curriculum, Empedocles was also the one who founded the Italian school of medicine (Russell, 1946). It has been argued that this school influenced the tendencies of scientific and philosophical thinking at the time, even having an influence on Plato and Aristotle later on (Russell, 1946). 

Empedocles amazingly was also the first person to come up with an idea that although very fantastic and archaic, somewhat resembles the Darwinian theory of evolution and survival of the fittest. According to Empedocles, initially, there were many tribes constituted of creatures with multiple shapes: neckless heads, arms without shoulders, eyes without heads. And these various limb/organ-creatures would roam around seeking to unite with each other. There would be a lot of unions that happened by chance, leading to creatures that had multiple hands as part of their body, creatures with multiple faces and breasts in all sorts of arrangements, and even unions of these limb/organ-creatures with other established animals such as bulls (Adamson, 2014; Kenny, 2010; Russell, 1946). However, only some of these unions would be suitable for survival and be able to reproduce, in a way that would eventually lead to the known human body (Kenny, 2010; Russell, 1946). Despite the overall narrative appearing Darwinian, as it is pointed out by Adamson (2014), it is missing a crucial characteristic that stops us from being able to call it a precursor of the modern theory of evolution: that certain inherited characteristics are selected and passed on through reproduction because they make animals and plants more likely to survive. Empedocles fails to give us an explanation of what causes some combinations of organs to make animals more suitable and allows them to survive and further reproduce. Still, his ability to foreshadow natural selection earned Empedocles the shoutout from Darwin in the lather’s 6th edition of the Origin of Species (Kenny, 2010).

Now we come to one of Empedocles’ most influential, although not scientific, theories, which is in the field of cosmology. The classical idea of earth, air, fire, and water as the four elements that constitute the universe was first established by Empedocles (Adamson, 2014; Kenny, 2010; Russell, 1946). According to him, all of these are everlasting and would be mixed in various ways, forming all the different things we see in the world. The forces that mixed them were none other than Love, which brought the elements together, and Strife, which separated them (Adamson, 2014; Kenny, 2010; Russell, 1946). This has been considered similar to Heraclitus’ cosmology, however, Empedocles rejected the former’s doctrine of Monism. (Russell, 1946). What causes things in the world to change and move is because there is an ongoing cyclical balance, almost a battle, between Love and Strife: when Love brings the elements closer, Strife gradually separates them; when Strife brings the elements further apart, Love gradually unites them (Adamson, 2014; Kenny, 2010; Russell, 1946). However, he would believe that these changes would happen by chance, the events in the universe not having a purpose (Russell, 1946). Here again, we see the pre-Socratic tendency of trying to understand and explain why things in the observable world move and change.

Practical demonstration of Empedocles elements creating everything in the world

To end Empedocles’ tale, his aspiration to godhood is said to have been his undoing, as supposedly he died when he jumped into the crater of the volcano Etna to prove his godly status (Adamson, 2014; Kenny, 2010; Russell, 1946). Talk about going out in a blaze! 

Empedocles was an interesting character, not just because of his extravagant belief in his own godhood, but because lived in dissonance between some parts of his theories being surprisingly scientific, more than some philosophers before and after him, and in others, he was still quite prone to superstition, with this aspect of his being influenced by Pythagoreanism (Adamson, 2014; Kenny, 2010; Russell, 1946) As pointed by Russel (1946), this is not much different than the cognitive dissonance displayed by people in scientific areas such as medicine, nutrition or energy production in the present. Just like the cycle of the elements between Love and Strife, time goes on, but some things never change. 

I hope that this continues to show that some of the ideas and ways of thinking common nowadays originated way earlier than we think and why it is still valuable to revisit the ideas of these past philosophers in search of enlightenment in our own life. 

As always, if you learned something and/or found this text interesting, please share it all over social media so you can help others learn. See you in the next one. 

References:

Adamson, P. 2014. Classical Philosophy: A history of philosophy without any gaps, Volume 1. 1st edition. Oxford University Press: Oxford. 

Kenny, A. 2010. A New History of Western Philosophy: In Four Parts. Reprint Edition. Oxford University Press: Oxford. 

Russell, B. 1946. History of Western Philosophy. Routledge – Taylor and Francis Group: New York. 

Back Pain Myth 3 – You have bad posture

In this text, I’m back to continue looking at some of the myths surrounding lower back pain. 

This time I’m looking at one of the myths that is very ingrained into our day-to-day life, from how we sleep, how we walk, how we dress, how we eat, how we work, and even how we do the things that we find enjoyable. It’s always there, always watching and judging what we do with our bodies. I’m talking about the myth of posture. 

Who has never, while growing up, been told by their mother that all their other health problems are caused because they spend so much time with their necks flexed on the phone or computer? Or told to sit upright by their teacher while at school? 

I didn’t read your mind and I haven’t been stalking you for most of your life to know this. It just has been well demonstrated that throughout the world, the general public and health care professionals often hold the belief that some postures are harmful and should be avoided (Christe, Nzamba et al, 2021; Christe, Pizzolato et al, 2021; Korakakis et al, 2019), typically considering the safest way to sit is avoiding spinal flexion (Slater et al, 2019) as a slightly extended posture is also often considered the best position (Slater et al., 2019).  

Despite these common beliefs, there is no strong evidence that avoiding what are deemed as incorrect postures prevents back pain (Slater et al., 2019). Which begs the question: why are we still calling them incorrect in the first place? 

Let’s try breaking this down. How about we first start by looking if ‘improving’ the way we hold our body (assuming there is a better and worse way of doing this) leads to less pain. 

Laird, Kent and Keatin (2012) performed a systematic review where they looked at studies examining the patterns of lumbar muscle activity, lumbo-pelvic kinematics (fancy way of saying how your pelvis moves), posture patterns and how these affected measures of pain and activity. The studies they found looked at different forms of exercising including the overhyped swiss ball and motor control exercises as well as measuring the electrical activity of your muscles or giving you real-time feedback of how your muscles are activating so you can change it (biodfeedback) (Laird, Kent and Keatin, 2012). Out of 12 studies, mostly of poor quality, only one found some improvement of pain, the others not showing any changes in pain or activity with the interventions, and on the one pain improved, there was no change in how the muscles were activating at the end of the study (Laird, Kent and Keatin, 2012). 

So doing some fancy exercises with the aim of improving your posture doesn’t seem to either improve your posture or reduce pain. The whole story about your core being weak and underactive and that is why your posture is poor and you’re in pain doesn’t seem to hold up. Lima et al (2018) actually found that people with lower back pain had increased activity of back muscles across different day to day tasks such as picking up and object from the ground or standing up. This makes me think that actually focusing on having your muscles very active all the time could actually make this worse. 

It has actually been shown the notion that people with low back pain must be careful and ‘protect’ their spine, thus bracing their muscles and moving in a more guarded way of moving is associated higher level of fear and lower self-efficacy (Slater et al., 2019) – ability to manage their own health. 

So far we’ve been talking about postures we can actively control. What about when we have deviations from the considered “ideal” posture that we can’t change, such as in the cases in which people have differences in the length of their legs and this to our spine not being completely straight. Sheha at all (2018) examined this in a literature review and reached the conclusion that the currently available evidence is often contradicting, with generally small, underpowered studies and few randomized trials, leaving us without a clear correlation between a difference in leg length and development of back pain. 

Possibly because of this poor correlation between posture and back pain, interventions focused on body alignment and posture such as back supports, shoe insoles and ergonomic programmes have shown to be ineffective on both preventing and treating lower back pain and are not recommended in guidelines (Foster et al, 2018) 

You may laugh, but this as effective as any other posture correction device out there.

So far we’ve seen that there is no match between how our muscles activate and our body moves or sits and having back pain; that even when attempts are made to change our posture, this doesn’t actually change our posture or improves pain; and even if out body doesn’t fit into this abstract ideal of symmetrical perfection, it doesn’t mean we will be developing back pain.As we have explored, the available research doesn’t allow us to establish a causal relationship between having a certain type of posture and developing back pain. We see that people can present with flexed postures, however we can’t say that isn’t a consequence of pain instead of the other way around.  

Yet, non-evidence-based beliefs about our posture being harmful still prevail and are reinforced by fear inducing messages in different forms of media around us (Slater et al., 2019). As I mentioned in a previous post, research suggests that these negative beliefs about back pain are what actually can make you experience worse pain, be more disabled by it and be less likely to recover (Burgess et al, 2020; Lee et al, 2015; Morton et al, 2019). A more useful message for your health is to not stay in the same posture for long, be it flexed or upright, and be active more often (Foster et al, 2018; NICE, 2020). You can add that to the list of benefits of exercising.

As a healthcare professional I feel responsible and thus I’m trying to debunk some of these myths and I hope I’ve managed to argue why you should to. If you think I argued my point well, a good place to start is by sharing this post with the people you know. 

If any part of this text didn’t make sense and you have questions, or you know about a piece of evidence that contradicts my argument please leave it in the comments. Dialogue is important to continue learning. 

I’ll see you the next one. Until then – keep learning. 

References:

Burgess, R., Mansell, G., Bishop, A., Lewis, M. and Hill, J. (2020). Predictors of functional outcome in musculoskeletal healthcare: An umbrella review, European Journal of Pain (United Kingdom), 24(1), pp. 51–70. doi: 10.1002/ejp.1483. 

Christe, G., Nzamba, J., Desarzens, L., Leuba, A., Darlow, B. and Pichonnaz, C. 2021. Physiotherapists’ attitudes and beliefs about low back pain influence their clinical decisions and advice, Musculoskeletal Science and Practice. Elsevier Ltd, 53(April), p. 102382. doi: 10.1016/j.msksp.2021.102382. 

Christe, G., Pizzolato, V., Meyer, M., Nzamba, J. and Pichonnaz, C. 2021. Unhelpful beliefs and attitudes about low back pain in the general population: A cross-sectional survey. Musculoskeletal Science and Practice. Elsevier Ltd, 52(August 2020), p. 102342. doi: 10.1016/j.msksp.2021.102342. 

Foster, N. E., Anema, J. R., Cherkin, D., Chou, R., Cohen, S. P., Gross, D. P., Ferreira, P. H., Fritz, J. M., Koes, B. W., Peul, W., Turner, J. A., Maher, C. G. (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions. In The Lancet (Vol. 391, Issue 10137, pp. 2368–2383). Lancet Publishing Group. https://doi.org/10.1016/S0140-6736(18)30489-6 

Korakakis, V., O’Sullivan, K., O’Sullivan, P. B., Evagelinou, V., Sotiralis, Y., Sideris, A., Sakellariou, K., Karanasios, S., & Giakas, G. (2019). Physiotherapist perceptions of optimal sitting and standing posture. Musculoskeletal Science and Practice, 39, 24–31. https://doi.org/10.1016/j.msksp.2018.11.004 

Laird, R. A., Kent, P., & Keating, J. L. (2012). Modifying patterns of movement in people with low back pain -does it help? A systematic review. In BMC Musculoskeletal Disorders (Vol. 13). BioMed Central Ltd. https://doi.org/10.1186/1471-2474-13-169 

Lee, H., Hübscher, M., Moseley, G. L., Kamper, S. J., Traeger, A. C., Mansell, G. and McAuley, J. H. (2015). How does pain lead to disability? A systematic review and meta-analysis of mediation studies in people with back and neck pain’, Pain, 156, pp. 988–997. doi: 10.1097/j.pain.0000000000000146. 

Lima, M., Ferreira, A. S., Reis, F. J. J., Paes, V., & Meziat-Filho, N. (2018). Chronic low back pain and back muscle activity during functional tasks. Gait and Posture, 61, 250–256. https://doi.org/10.1016/j.gaitpost.2018.01.021 

Morton, L., de Bruin, M., Krajewska, M., Whibley, D. and Macfarlane, G. J. (2019). Beliefs about back pain and pain management behaviours, and their associations in the general population: A systematic review, European Journal of Pain (United Kingdom), 23(1), pp. 15–30. doi: 10.1002/ejp.1285. 

National Institute for Health and Care Excellence (NICE). 2020. Low back pain and sciatica in over 16s: assessment and management NICE Guideline [NG59], December 2020. [Online]. Available at: < https://www.nice.org.uk/guidance/ng59/resources/low-back-pain-and-sciatica-in-over-16s-assessment-and-management-pdf-1837521693637

Sheha, E. D., Steinhaus, M. E., Kim, H. J., Cunningham, M. E., Fragomen, A. T., & Rozbruch, S. R. (2018). Leg-Length Discrepancy, Functional Scoliosis, and Low Back Pain. In JBJS reviews (Vol. 6, Issue 8, p. e6). NLM (Medline). https://doi.org/10.2106/JBJS.RVW.17.00148 

Slater, D., Korakakis, V., O’Sullivan, P., Nolan, D., & O’Sullivan, K. (2019). “Sit up straight”: Time to Re-evaluate. In Journal of Orthopaedic and Sports Physical Therapy (Vol. 49, Issue 8, pp. 562–564). Movement Science Media. https://doi.org/10.2519/jospt.2019.0610 

The Pre-Socratics part 4 – Mixing things up

Often, Athens is considered to be the cradle of Greek philosophy. However, you have by now probably noticed that none of the philosophers we have looked at so far as come from Athens, or even have spent a lot of their time there. Anaxagoras was the first philosopher to have spent most of his time and done most of his philosophy in Athens (Adamson, 2014). Due to this, some have held Anaxagoras as being the one moving philosophy from Ionia to Athens and as the most prominent philosopher of Athens until the arrival of Socrates, the later possibly never becoming a renowned philosopher if this hadn’t happened (Adamson, 2014; Russell, 1946).

There is as a kind of duality in Anaxagoras’ philosophy. On one side there is the very esoteric idea of the exalted Mind as the purest and most subtle of things, which has a central role in creating the cosmos (Adamson, 2014).

According to Anaxagoras the cosmos was created and ordered by the Mind, the Mind being infinite and controlling everything that lives (Adamson, 2014). However this Mind is not like a god, but something responsible for the capabilities of certain beings, for example humans or animals, such as why they can think, see and move (Adamson, 2014). Mind is not distributed equally throughout all beings, humans supposedly having more than other beings, for example giraffes, and giraffes having more than insects (Adamson, 2014¸ Russell, 1946). Non-living things like rocks don’t have Mind (Adamson, 2014; Russell, 1946).

Despite the impressive muscles, according to Anaxagoras The Rock would not have Mind. Talk about enforcing meathead stereotypes.

On the other side, Anaxagoras displays a fascination with physical processes in addition to his theory of universal mixture: everything is in everything (except the Mind, of course) (Adamson, 2014; Russell, 1946). The Mind is, however, involved in this theory, having a central role in the creation of the universe: Before the universe was formed, there only existed Mind and another infinite substance that had everything else mixed together, Mind being the only thing outside of it (Adamson, 2014; Russell, 1946). Mind then starts spinning the infinite substance around. In this substance there were also what Anaxagoras called ‘seeds’, which were the beginnings of later separate substances such as water or air (Adamson, 2014; Russell, 1946). Whit the spinning of the infinite mixture, the seeds of lighter things are moved towards the edge of the mixture, becoming air and fire, while the seeds of moist and dense things stay around the middle (Adamson, 2014). Anaxagoras also describes that at some point a number of large stones spin out of the middle of the mixture, burning very hot and white, becoming the visible heavenly bodies such as the sun and moon (Adamson, 2014).

So far this sounds quite similar to the previous idea of Anaximenes of how the cosmos is organised, with the addition of the Mind which moves things just thinking about it (Adamson, 2014). However, Anaxagoras adds in an idea of his own, which is presented in one of his most well known phrases: “everything is in everything” (Adamson, 2014; Russell, 1946). Only the Mind is completely separated from everything else.

Aristotles (who will cover eventually) was actually who first came up with a contextualization of this theory that is presently still accepted by some scholars. Anaxagoras’ theory is likely to be inside the context of the denial of change we previously saw in Parmenides (Adamson, 2014). In an attempt to answer to the impossibility of anything coming into being from non-being, Anaxagoras starts by accepting this part of the reasoning but refuses to accept that nothing can change or move. He argues that we do not need absolute because everything is already in everything (Adamson, 2014). He justifies this through a curious example which I will slightly paraphrase: when you eat some hummus, or any other food, it will restore the flesh, bone and blood of your body. This means that there must be some flesh, bone and blood in that hummus, because there is nowhere else for it to come from (Adamson, 2014).

Practical applications of Anaxagoras theory of everything being in everything (Toy Story and all associated characters were created and are owned by Walt Disney Pirctures; Jojo’s Bizarre Adventure and all associated characters was created and belongs to Hirohiko Araki, being distributed by Jump Comics and Viz Media)

Still following the same line of thought, Anaxagoras also accepted Zeno’s paradox of being able to divide any material an infinite number of times, but argued that no matter how small of a portion something is divided into, it will still contain everything in it (Adamson, 2014; Russell, 1946).

With his theory, Anaxagoras introduced a question that was often part of ancient attempts to try to understand the nature of material objects and one that would entertain the minds of generations of philosophers to come: what does it mean for something to be mixed with another? (Adamson, 2014). Anaxagoras exemplifies the bold tendency of 5th century philosophy to build systems in an attempt to understand the nature of the universe (Adamson, 2014). Other examples of this were Anaxagoras being recognised as the first to theorize the moon shines by reflecting light, to give the accurate explanation to solar eclipses and as previously mentioned, theorize that the sun and stars are stones of fire, clearly displaying he carried the scientific and rationalist tradition of the Ionians to Athens (Russell, 1946).

I hope this helps to show, once again, how influential the ideas of ancient Greek philosophers were and why we still study them currently. We have inherited their pursuit of understand the universe around them.

But we are not out of ideas and theories to explore yet, even though this text will end here. As always, if you learned something and/or found this text interesting, please share it all over social media so you can help others learn. See you in the next one.

References:

Adamson, P. 2014. Classical Philosophy: A history of philosophy without any gaps, Volume 1. 1st edition. Oxford University Press: Oxford.

Russell, B. 1946. History of Western Philosophy. Routledge – Taylor and Francis Group: New York.

Back Pain Myth 2 – Scan it

I’ll again be looking at some of the myths surrounding back pain and our spine. If you haven’t already, I advise you to read part 1 as in it I explain why these myths can be bad for you and why I think it is important to address them. In it, I have given an explanation on serious back pathologies being rare and that our back hurting often does not mean we have injured something.

Today I want to look at MRI scans, x-rays and the sort of investigations that usually give us an actual picture of our back, and try to understand what they role is in the management of back pain.

It may have been that some of you have been to your doctor or physiotherapist due to having really bad pain on your back. It was so bad that it felt like something inside your spine came out or was crushed – something bad happened surely. But when you went to your doctor they didn’t mention having a scan or even told you they don’t need one. How can they now what is wrong if they don’t use a scan to look into the actual spine?

The problem with this line of reasoning is that scans can’t show us pain.

Scans can show us the appearance of structures – bones, ligaments, cartilage, fluid, fat – in our body. Some of these structures are expected to appear a certain way in a scan, be it in terms of shape, size, how dark or bright they look. The problem starts when we look at the data investigating what looks “normal” (a word I would argue that has very limited value in healthcare) and what doesn’t.

A study by Brinjikji et al (2015) looked at how common some so called structural changes – changes in how the brightness of a disc looks in a scan, the size of the discs in our spine, changes in the shape of the joints in our spine – in people without any pain. They found that even in people who are 20 years of age, disc bulges were present in 30% , disc protrusions in 29% and disc degeneration in 37%. These values tend to increase with age, with disc bulges and degeneration being present in over 70%, reduction of disc thickness in 56%, degeneration of joint facet in 32% and disc fissures in 23% of people who are 50 years old.

In another review by Teraguchi et al (2018), the discs with brighter than normal zones on MRI were found in between 20-24% of people. In a more recent population-based study by Kasch et al (2020) limited to Germany but with a large sample 3369 people followed from 2008 to 2019, 74.4% of people without pain had at least one finding on MRI.

When you look at epidemiological data, there are more and less useful ways of looking at scan findings.

Even something as scary as spondylolisthesis, actual sliding of a vertebral body in relation to the ones around it as a result of a small fracture (and no, this is not what people mean when your vertebrae come out of alignment nor it can or should be treated with manipulation or manual therapy of any kind) will be present in 50% percent of people who are 80 years of age (Brinjikji et al, 2015). And in case you had forgotten, this is all in people without any symptoms – no pain, no leg tingling, nothing.

The next thing to consider with scans to our spine is that some of the changes that can be seen also often return to normal if we just wait.

In a systematic review by Chiu et al (2015) it was found that  herniated discs will reduce over time, from 13% of minor bulges reducing and 11% completely resolving, to 96% of the very serious disc herniations where part of the disc has almost fully separated from the main disc reducing in size and 43% completely resolving. You read that right:  the worse ones are much more likely to improve without any sort of treatment.

The last thing to consider is if having a scan would change how we treat back pain. As we have seen so far, what the scan shows and what symptoms you get or how bad they are don’t really match up. Looking again at the study by Kasch et al (2020), after following up people and comparing their symptoms at baseline with how they presented after 11 years, the MRI findings did not match or predict the severity or presence of symptoms. Based on this information and referring specifically to back pain, because we are not able to match what is shown on a scan with your pain, we also can’t really use it to inform how we are going to treat you. A systematic review by Karel et al (2015) showed that having an early scan did not offer any improvement on pain, function, satisfaction, quality of life and overall improvement in people with back pain, on either short- or long-term follow up. As argued by Brinjikji et al (2015), this all suggests that these findings are just part of life and the natural processes of our body rather than something pathologic that needs treatment. Isn’t our body amazing and resilient?

Our bodies are resilient, dynamic and adaptive systems. Treat them as such.

I hope that what I have described so far has helped you understand why when being assessed by a health professional, unless certain other symptoms are present besides pain, they will try discouraging you from having a scan to your back. At least they will try to do this if they are up to date with the major present clinical guidelines, which all advise against routine use of scans for back pain (Cuff, 2020). And believe me in that if there are any symptoms of anything more serious being present – which pain on its own isn’t – your doctor or physiotherapist will suggest it before you.

We – both clinicians and members of the public – often think that scans can be this miraculous window into our body that will tell us straight away what is happening. However, as we have established, pain is a complex and non-straightforward thing. Even very high-tech scans are surrounded by a lot of uncertainty when it comes to showing causes of pain.

I hope this text has helped you understand a bit more about where this uncertainty comes from and what the research shows on the effectiveness and usefulness of scans. If you are a member of the general public and the clinician you’re seeing advises against a scan, take is as an honest understanding of how little it may help. If you are a healthcare professional, use the research cited to better understand the limitations of the imaging technology we have available and to avoid over-medicalizing what are actually normal findings in healthy people. We have a responsibility to be well informed and not give bad advice to the people who come to us for help.

As always, share this text throughout social media if you felt you learned something from it. Feel free to ask any questions in the comments and I hope you will return for the next one.

References:

Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., Halabi, S., Turner, J. A., Avins, A. L., James, K., Wald, J. T., Kallmes, D. F. and Jarvik, J. G. 2015. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. Am J Neuroradiol, 36(4),  pp.811-16 DOI: https://doi.org/10.3174/ajnr.A4173

Chiu, C.-C., Chuang, T.-Y., Chang, K.-H., Wu, C.-H., Lin, P.-W., & Hsu, W.-Y. 201. The probability of spontaneous regression of lumbar herniated disc: a systematic review. Clinical Rehabilitation, 29(2), 184–195. doi:10.1177/0269215514540919

Cuff, A., Parton, S., Tyer, R., Dikomitis, L., Foster, N. and Littlewood, C. 2020. Guidelines for the use of diagnostic imaging in musculoskeletal pain conditions affecting the lower back, knee and shoulder: A scoping review, Musculoskeletal Care, 18(4), pp. 546–554. doi: 10.1002/msc.1497.

Jensen, R. K., Jensen, T. S., Koes, B. and Hartvigsen, J. 2020. Prevalence of lumbar spinal stenosis in general and clinical populations: a systematic review and meta-analysis, European Spine Journal. Springer Berlin Heidelberg, 29(9), pp. 2143–2163. doi: 10.1007/s00586-020-06339-1.

Kasch, R., Truthmann, J., Hancock, M. J., Maher, C. G., Otto, M., Nell, C., Reichwein, N., Bülow, R., Chenoti, J.-F., Hofer, A., Wassilew, G. and Schmidt, C. O.  2021. Association of Lumbar MRI Findings with Current and Future Back Pain in a Population-Based Cohort Study, Spine, 0. doi: 10.1097/BRS.0000000000004198.

Teraguchi, M., Yim, R., Cheung, J. P.-Y. and Samartzis, D. 2018. The association of high-intensity zones on MRI and low back pain: a systematic review, Scoliosis and Spinal Disorders. Scoliosis and Spinal Disorders, 13(1), pp. 14–19. doi: 10.1186/s13013-018-0168-9.