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 tend to consider things that are easier to recall, either due to happening recently or their impact on us, as occurring more frequently than they actually 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.

The Pre-Socratics part 3 – Atomic theories

Welcome back to our exploration of the beginning and development of philosophy. In this text, I will be discussing an idea that originated with the ancient Greek philosophers and has actually been shown to be true by modern science – the idea that all bodies (living and non-living) are composed of very small particles that are not visible to the naked eye, and which the interactions of explain most, if not all, phenomena we see in the world (Adamson, 2014; Russell 1946). These particles are atoms and yes, the idea of atoms originated in 5th century BC Greece (Adamson, 2014; Russell, 1946). Looking at the origins of the word ‘atom’ itself, in ancient Greek, tomein means “to cut” and atoma means “uncuttables”, things that cannot be cut or divided into smaller parts due to being indivisible by nature (Adamson, 2014). We now understand that the concept has since evolved, as ancient atoms are different from modern atoms, which are actually divisible into smaller protons, electrons and neutrons, which in turn are divisible again into quarks – I apologize if I there has been a recent development about the name or nature of these last ones, but as a physiotherapist trying to dip into philosophy, I’m still a victim of my own ignorance.

The idea of atoms first originated with two philosophers, Leucippus and Democritus (Adamson, 2014; Russell 1946). To understand how they have reached this idea, I first have to briefly mention a previous philosopher who was known for coming up with mind-boggling paradoxes: Zeno of Elea (Adamson, 2014), as often the atomists developed their theories in response to these paradoxes (Adamson, 2014). One of such paradoxes was the dichotomy paradox: let’s say you want to walk across any distance, for example from your couch to the kitchen to grab a piece of chocolate or some nice hummus. To walk that distance you first have to walk half that distance, and for you to do that you need to walk half of that half distance, but before you do that you need to walk half of that half of half the distance, and so on to infinity (Adamson, 2014). Because there are a infinite number of halves to the distance you have to travel, it is impossible to actually travel it – no hummus for you.

Another example was a paradox regarding how many things existed in the world, if reality is a unity like proposed by Parmenides (if you don’t know who this is, check my previous text on the pre-socratics here) or if more than one thing exists. This one goes like this: Imagine two objects, for example a mug and a laptop. We can see they’re not a single continuous object, so they must be separated from one another. We then assume then there is a third object, separating them. But then, who are the mug and the laptop different from this third object? There is probably a fourth and fifth object separate the mug from the third object and the laptop from the third object (Adamson, 2014) – I think you see were this is going.

I’m not going to answer these for you. I’ll let you think about them while they keep you awake at night due to the existential dread of your understanding of the nature of reality shattering before you.

The value of these paradoxes is that they made us and philosophers think about the nature of motion, time and physical boundaries (Adamson, 2014). It was also in response to these paradoxes that atomists theorized that if you just kept dividing something, you would eventually get to something that you’re unable to divide any further (Adamson, 2014).

Together with atoms, the atomists were also the first ones to come up with the concept of empty space, or void (Adamson, 2014). This may not seem that revolutionary of a concept, but if we take into account Parmenides rejection of non-being and Zeno’s paradox about what separates objects, we can appreciate that empty space was out of the ordinary for the time. But what were these ancient atoms like? Leucippus and Democritus proposed that all larger bodies are made of atoms, which can both collide and be gathered together. There are an infinite number of atoms and they are of many varied shapes, in contrast to present day uniform shape of modern atoms (Adamson, 2014; Russell 1946). Some are even hooked or have several curves, so they nicely attached if they come together, just like the pieces of a puzzle (Adamson, 2014). The different shape of the atoms would also explain the different shapes of the larger bodies they make (Adamson, 2014). Leucippus and Democritus also attempted explaining how the universe formed out of atoms. Going with their tendency to collide with each other, atoms don’t just bounce of each other, but due to their matching shapes, atoms will aggregate with other atoms similar in shape and size (Adamson, 2014). Together with this aggregation, massive groups of atoms throughout the cosmos will swirl around in vortexes, with the heavier atoms grouping in the middle and forming the earth and the lighter atoms grouping on the outside, forming the heavens (Adamson, 2014; Russell 1946). Following this reasoning, the atomists also thought that the infinite amount of atoms that exist means that there will be an infinite number of cosmos (Adamson, 2014). These cosmos would basically be parallel Earths that are either completely different – like an Earth made completely of hummus – or with just a slight difference – hummus is golden – with everything else being the same (Adamson, 2014).

Note to self: Stop writing while hungry

I find this whole theory fascinating as, besides predicting atoms as one of the fundamental constituents of matter, it also closely resembles how galaxies, stars and planets formed after the big-bang, with groups of molecules ending up nearby and their own gravitic pull aggregating them together. Even though in part this theory was developed in response to Parmenides, Democritus did express some things in common with him. Just like Parmenides described his way of truth as following deductive arguments due to the senses deceiving us to the truth of reality, Democritus also argued that the world as seen by the senses is unreal as it does not capture the fundamental reality of atoms and void (Adamson, 2014) – if something looks blue, feels hot, or tastes salty, there is no blue, hotness or saltiness, only the interactions of atoms that create the appearance of those (Adamson, 2014). In this theory we continue to see the ancient Greek tendency to value deductive means of reaching knowledge as opposed to the inductive process of direct observations (If these terms are confusing you, go check part 1 of the pre-socratics, were I provide a full explanation). Which in itself is not inherently wrong, we are often deceived by our own senses and personal experiences. They can provide us a very limited view of the universe and the phenomena in it. However does that mean reality isn’t, well, real? Present day science confirms the existence of atoms and other particles that we can’t perceive with our eyes. Adamson (2014) raises a pertinent question in regards to this. When a scientific theory is proved and shows that the world is very different from how we perceive it, does the scientific theory replace the phenomenal world (world as perceived by the senses) with a world only perceived by specialized means, or is the phenomenal world maintained with our understanding and experience of it being enhanced by science?

I would argue that both deduction and induction are needed. We can have the starting point of formulating a theory through deduction, but the only way to prove that theory is through putting it through the test in how it explains the phenomena of the world. If the conclusions of testing don’t match reality, than that theory is not a good one. And then we are back to updating our theory through deduction, but even this deduction is inductively informed by the previous observations from experimental testing. Deduction and induction actually appear to work better together, why set them against each other?

But what do you think? Are deduction and pure reason the means through which we can actually understand how the world works? Or even though the senses can sometimes elude us, only by observing the world through our senses can we understand it? Or have you been sold on my perspective of both have their role and can contribute to improving our understanding of the world?

We haven’t finished the Pre-Socratic philosopher yet – there are a lot more than I thought. So stick around while I try to better understand where knowledge comes from. Not that you can really move according to Zeno.

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.

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

Back Pain Myth 1 – Something is broken

This is text will be the first in a series through which I want to address some myths that are still very prevalent in our society, be it in you, member of the general public, or among health care professionals.

Why am I focusing on back pain? The 2015 Global Burden of Disease Study identified that since 1990, low back pain has remained the leading cause of disability worldwide (Hurtwitz et al, 2018).

Now, let me explain why it is important we address certain myths, before we actually get to them.

It has been shown by research that throughout the general population of different countries, a lot of negative and often misinformed beliefs about back pain are still present (Christe et al, 2021b; Morton et al, 2019). These beliefs include things such as the back requiring protection, the back being vulnerable, the back being damaged and requiring special attention or treatment, or having to take time off from work to rest (Christe et al, 2021b; Morton et al, 2019)

Is this a problem? People can believe what they want, that won’t change reality, right? In this particular case, there is research indicating that having negative beliefs about back pain will make you experience worse pain, be more disabled by it and have a worse chance of improving and returning to your normal day to day (Burgess et al, 2020; Lee et al, 2015; Morton et al, 2019).

As I said, this problem is no limited to you, member of the general public. No, we healthcare professionals are also to blame. Looking at my own neck of the woods, beliefs about the back requiring special protection, good posture being important for protecting it, and that back pain requires special attention or treatment are still quite present amongst physiotherapists (Christe et al, 2021a).

This study by Christe et al (2021a) also suggests that physiotherapists with unhelpful beliefs are more likely to make their treatment plan and advice towards rest and avoidance of activities. This will contribute to poor care as it is likely to reinforce the aforementioned negative beliefs in people who seek treatment (Gardner et al, 2017), as well as being exactly the opposite of what is recommended in most clinical literature and guidelines (Lin et al, 2020; NICE, 2020).

So how do we tackle this problem? Using what I would argue to be one of the best tools we have to make the world a better place: education, of course. The importance and role of education, including the spreading of up-to-date messages, as part of the management of back pain has already been highlighted throughout the clinical literature (Buchbinder et al, 2018; Caneiro et al, 2020; Lin et al, 2020; Lewis and O’Sullivan, 2018; NICE, 2020).

Let’s get started by looking at one of the more prevalent myths surrounding back pain and how it has been shown to be incorrect.

Myth: Back pain is caused by damage in the back.

We can start addressing this myth by recalling that pain is not always associated with, and therefore, is a poor measure of the status of our tissues. If you want to learn more about this and the nature of pain in general, I’ve previously written a two part post about pain and its complexity. You can read both parts here and here.

Overall back pain is a quite common symptoms from younger to older age (Draheim and Hügle, 2018; Hoy et al, 2012) and it is rarely associated with a specific or serious problem. Historically, the percentage of people who have low back pain without it being caused by an injury or a pathology has been estimated to be around 90% (Koes, van Tulder and Thomas, 2006).

Putting this value under a different perspective, research looking at the amount of people who actually have a serious injury or pathology (medical problem) associated with back pain has estimated it to be lower that 1% of cases of back pain, ranging from 0.002% to 0.9% depending on the specific pathology (Finucane, 2020; Henschke et al, 2009) It is also important to note that in these cases, for a serious pathology to be suspected, other symptoms beside pain need to present, as mentioned above, pain itself is not an indicator of an injury, even if it feels very intense and severe.

Even these symptoms that are suggestive of something more serious – usually called ‘red flags’ by health care professionals – are often present, usually at least one, in people suffering with back pain, even if the person doesn’t actually have the pathology (Henschke et al, 2009).

Now, in no way this is me suggesting that this pain not be very disabling and limiting, quite the opposite. However it means that even if pain is very severe, the chance of it being life-threatening is very, very low.

Concluding, back pain is something very common throughout our lives and only very, very rarely caused by a serious problem, even when the pain feels very intense. I hope knowing this is helpful to you, either helping you understand a bit more about the pain you might be feeling, or if you are someone whose work involves helping people with pain.

Don’t forget that when in doubt, check with a certified medical doctor or a physiotherapist. When we next return to the myths surrounding back pain, I will explain why your doctor won’t always send you for a scan and why what you probably have been told about posture for most of your life doesn’t really matter that much. If you liked this text and feel you learned something from it, please share it around social media. If you want to make any remarks or ask any questions, feel free to do it in the comments.

References:

Buchbinder, R., van Tulder, M., Öberg, B., Costa, L. M., Woolf, A., Schoene, M., Croft, P., Hartvigsen, J., Cherkin, D., Foster, N. E., Maher, C. G., Underwood, M., Anema, J. R., Chou, R., Cohen, S. P., Ferreira, M., Ferreira, P. H., Fritz, J. M., Genevay, S., Gross, D. P., Hancock, M. J., Hoy, D., Karppinen, J., Koes, B. W., Kongsted, A., Louw, Q., Peul, W. C., Pransky, G., Sieper, J., Smeets, R. J. and Turner, J. A. (2018) ‘Low back pain: a call for action’, The Lancet, 391(10137), pp. 2384–2388. doi: 10.1016/S0140-6736(18)30488-4.

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.

Caneiro, J. P., Roos, E. M., Barton, C. J., O’Sullivan, K., Kent, P., Lin, I., Choong, P., Crossley, K. M., Hartvigsen, J., Smith, A. J. and O’Sullivan, P. (2020) ‘It is time to move beyond a € body region silos’ to manage musculoskeletal pain: Five actions to change clinical practice’, British Journal of Sports Medicine, 54(8), pp. 438–439. doi: 10.1136/bjsports-2018-100488.

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.

Darlow, B., Dean, S., Perry, M., Mathieson, F., Baxter, G.D., Dowell, A. 2015. Easy to Harm, Hard to heal: patient views about the back. Spine. Wolters Kluwer Health Inc, 40(11), pp. 842-850

Draheim, N. and Hügle, B. 2018. Chronic musculoskeletal pain in children and adolescents’, Manuelle Medizin, 56(6), pp. 440–446. doi: 10.1007/s00337-018-0484-4.

Finucane, L. M., Downie, A., Mercer, C., Greenhalgh, S. M., Boissonnault, W. G., Pool-Goudzwaard, A. L., … Selfe, J. (2020). International Framework for Red Flags for Potential Serious Spinal Pathologies. Journal of Orthopaedic & Sports Physical Therapy, 1–23. https://doi.org/10.2519/jospt.2020.9971

Gardner, T., Refshauge, K., Smith, L., McAuley, J., Hübscher, M. and Goodall, S. 2017. Physiotherapists’ beliefs and attitudes influence clinical practice in chronic low back pain: a systematic review of quantitative and qualitative studies, Journal of Physiotherapy. Korea Institute of Oriental Medicine, 63(3), pp. 132–143. doi: 10.1016/j.jphys.2017.05.017.

Hoy, D., Bain, C., Williams, G., March, L., Brooks, P., Blyth, F., Woolf, A., Vos, T. and Buchbinder, R. 2012. A systematic review of the global prevalence of low back pain, Arthritis and Rheumatism, 64(6), pp. 2028–2037. doi: 10.1002/art.34347.

Lewis, J. and O’Sullivan, P. O. 2018. Is it time to reframe how we care for people with non-traumatic musculoskeletal pain ?, Br J Sports Med, pp. 1–2. doi: 10.1136/bjsports-2018-099198.

Lin, I., Wiles, L., Waller, R., Goucke, R., Nagree, Y., Gibberd, M., Straker, L., Maher, C. G. and O’Sullivan, P. P. B. (2020) What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: Systematic review, British Journal of Sports Medicine, 54(2), pp. 79–86. doi: 10.1136/bjsports-2018-099878.

UK 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 >

Henschke, N., Maher, C. G., Refshauge, K. M., Herbert, R. D., Cumming, R. G., Bleasel, J., York, J., Das, A. and McAuley, J. H. 2009. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain, Arthritis and Rheumatism, 60(10), pp. 3072–3080. doi: 10.1002/art.24853.

Hurwitz, E.L., Randhawa, K., Yu, H., Côté, P., Haldeman, S. 2018, The Global Spine Care Initiative: a summary of the global burden of low back and neck pain studies. European Spine Journal, [e-journal]27, pp.796-801. Available through: https://link.springer.com/article/10.1007/s00586-017-5432-9

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.

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.

Koes, B. W., van Tulder, M. W., Thomas, S. 2006. Diagnosis and treatment of low back pain, BMJ, 332, p. 1430-4. doi: 10.1136/bmj.332.7555.1430 

The Pre-Socratics part 2 – All is One, One is All

Welcome back to our delve into the world of philosophy in search of were a lot of our present day ideas have originated from and the search for knowledge has developed over the years. Last time we had finished learning the origin and meaning of the word ‘philosophy’ itself and pondering on some of the great questions that were started by philosophers and mostly still prevail to present day.

The next philosopher, Heraclitus, will pick up on one of those questions and will continue the pre-socratic trend of identifying a fundamental principle of the universe (Adamson, 2014).

Another common trend for pre-socratic philosophers was to try explaining change and opposition. In a sense seeking to answer both questions, Heraclitus thought that everything in the world formed a unity that was composed of opposites (Adamson, 2014; Russell, 1946). This was Heraclitus’ core doctrine and main teaching of his philosophy: everything there is, is a unified whole, but a whole which includes many different things (Adamson, 2014). This firm idea that everything is part of a unity is called monism, and Heraclitus was the first philosopher to endorse it (Adamson, 2014). Heraclitus defended that opposites combine in strife, producing a harmony. Due to this he valued war and hardship, as he thought that everything was made and passed away through strife (Russell, 1946). There is unity in the world, but this unity results from diversity (Russell, 1946). Heraclitus goes so far as to argue that there would be no unity if there were no opposites to combine (Russell, 1946).

Looking and the person himself, form what is recorded of him, Heraclitus does not appear to be a friendly character, as he would often criticize his contemporary and preceding philosophers, including Pythagoras (Russell, 1946), as well as humankind as a whole. He is believed to have said that humans are selfish and will only act for their own good. Maybe he was just applying his theory and trying to create harmony through strife.

His second most prized doctrine is that of everything being in a constant state of flux – that our world is a world in perpetual change (Russell, 1946).

He often would express his theories through one-liners, even writing a book full of these. ‘You cannot step twice into the same river; for fresh waters are ever flowing in upon you.’ (Adamson, 2014; Russell 1946) Even though this book and his peculiar way of resenting his philosophy earned him the nickname “the riddler”, it was in this book that Heraclitus first introduced to philosophy a very useful word – logos (Adamson, 2014).

If Heraclitus was known as ‘the riddler’, do you think there was also a pre-socratic Batman? Maybe he lived in Plato’s cave.

Logos means something like ‘word’, but with a meaning that also expands to ‘account’ and ‘reason’(Adamson, 2014). Difficult to translate, but logos is very useful, as it will allow to create all words that end in ‘-ology’. For example, ‘antropology’ is ‘giving an account’ (logos) of man (anthropos) and ‘biology’ means giving an account (logos) of life (bios) (Adamson, 2014).

Heraclitus theory of perpetual flux can be very uncomfortable, as it means nothing ever remains the same. Science has been fighting against this notion, trying to find some type of everlasting, permanent substance (Russell, 1946).  I think the positive idea we can take from this is that just as the things we like will change and end, so will the bad moments and things we don’t like.

Possibly as a culmination of his idea that reality is in a state of flux and the harmony of opposites through strife, Heraclitus said that Fire was the fundamental substance (Adamson, 2014; Russell, 1946).

Heraclitus explored multiple subjects and pioneered a style of systematic and all-encompassing philosophy that will be continued by this next philosopher: Parmenides (Adamson, 2014), who lived in the fifth century BC and was from Elea in Italy (Adamson, 2014; Russell, 1946).

Parmenides can be said to be the first philosopher to have a clear interest in metaphysics – the study of existence and what exists (Adamson, 2014; Russell, 1946). Like Heraclitus, Parmenides has a similar doctrine of unity, saying that reality itself is one (Adamson, 2014).  In opposition to Heraclitus, Parmenides claims that this unity exists because nothing ever changes or moves (Adamson, 2014; Russell, 1946). It is curious how the same conclusion about the nature of reality can be reached by two opposed theories – maybe Heraclitus was right about opposites combining into harmony. Parmenides goes so far as saying that any type of multiplicity such as different objects, colours or even different events happening at different times are mere illusion (Adamson, 2014; Russell, 1946). Parmenides reached this extreme world view through his belief that he can understand the nature of all reality using purely abstract arguments. He justified this, simultaneously enriching epistemology, by exploring the differences between belief and genuine knowledge. In his well-known poem, “On Nature”, Parmenides talks about the way of opinion and the way of truth (Russell, 1946), warning us that the way of belief is not as firmly grounded as the way of truth, not being trust-worthy (Adamson, 2014; Russell, 1946). The main message of the poem is that we should not trust the senses and instead follow philosophical argument to wherever it may lead (Adamson, 2014; Russell, 1946).

Illustration of Parmenides talking about the way of truth, colourized.

We see again deduction appearing in the stage of philosophy, with Parmenides basing his arguments on pure reason as opposed to observations about the world around us (Adamson, 2014). But what is the actual deduction Parmenides uses to reach the conclusion that everything is a unity and nothing ever changes or moves?

Parmenides starts by looking at two paths of reasoning about everything that exists: either something “is and must be”, or something “isn’t and can’t be”, that is his question. He immediately rejects the second option because it involves thinking about things that do not exist and we can’t think about non-being in a meaningful way (Adamson, 2014). This is because, according to Parmenides, when you think or use a name, you must think of or use the name of something, thus, thought and language require a subject outside of themselves (Russell, 1946).

He also comes up with a third option, where something “is and is not”, but expresses this is an even worse path of enquiry because it is contradictory in addition to also including thinking about non-existence (Adamson, 2014).

So, Parmenides decides the path of being, ‘is and must be’, is the one worth following for the way of truth. He then starts by pointing out that being cannot ‘begin’ to be, and neither can be destroyed, as that would involve coming from or becoming ‘non-being’ – and we don’t talk about that under Parmenides’ rules (Adamson, 2014). This is the line of reasoning that makes Parmenides argue that nothing changes, as it would involve something coming from or going into ‘non-being’ (Adamson, 2014). However we can easily argue back that not all change involves creation or destruction. If we observe an octopus in its natural habitat, it can easily change colour, for example from its normal pink to green, without the involvement of non-being. Well, Parmenides would disagree and say that the green of the green octopus replaces the non-being of green in the octopus or that the green octopus comes to being after there is no green octopus (Adamson, 2014). This serves as an argument for the unity of being over time – because there is no change, something can’t be something at one time and another thing at another time – as well as at any given time – if there was a change, a part of it would have to be different from another, which would require non-being (Adamson, 2014). Another implication from this argument is that being is continuous and that there can be no division of being, as the separation would involve gaps of non-being (Adamson, 2014). I, for one, can argue that all this metaphysics is causing a headache to come from non-being into my head.

The issue with this argument is that Parmenides assumes that words don’t have meaning in themselves, always having to refer to something that exists, ant that they have a constant meaning, always being used to refer to the same something (Russell, 1946). We know this is not always the case. I particularly like the example given by Russell (1946), about the word ‘Unicorn’. We utilise this word to refer to something we all know is imaginary, but despite it not existing, some sentences using the word ‘unicorn’ can be true and others can be false. If I say that a unicorn has one horn and cows have two horns, we need only to look at a herd of cows and count the number of horns. However, in the case of the unicorn the only evidence for the supposed number of horns would be in fantasy books. Considering this, instead of ‘Unicorns have one horn’, the correct statement would be ‘Certain books assert that there are animals with one horn called “unicorns”.’, because all statements about unicorns are actually about the word ‘unicorn’ itself (Russell, 1946).

Despite the somewhat fallacious nature of the argument, it represented a development in philosophy as Parmenides was performing a logical deduction, starting from the principle of “accepting ‘being’ and rejecting ‘non-being’” and following any consequences of that assumption (Adamson, 2014; Russell, 1946). He offers and explanation for the abstract phenomenon of being itself through applying reason above the information of the senses to reach a systematic deductive argument (Adamson, 2014). Together with this, his arguments about words always referring to something out of themselves started the concept of substance as the persistent subject of varying predicates, which has remained one of the fundamental concepts of philosophy, psychology, physics and theology since then (Russell, 1946).

 I admire Parmenides’ intellectual consistence and the willingness to pursue an argument to wherever it may lead, even if its conclusions defy common sense. Our personal experiences as informed by our senses can lead us to see patterns where there are none and make mistakes. However as we can see in Parmenides example, applying logic in a way that ignores reality can also lead to mistakes. This is just the start of the debate between pure logic and observation as a means of obtaining knowledge, which will last for many centuries.

But what about you? What do you think is the way of Truth?

We haven’t finished the pre-Socratic philosophers yet – there are a lot more than I thought. So stick around while I try to better understand the nature of knowledge and how we can obtain it.

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.

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

Exercise: The ignored wonderpill

 Exercise has been more popular than ever. For some years it’s been the thing everyone in healthcare talks about. During the first lockdown one of the trendy things was to join some type of online exercise group or do a zoom workout with your buddies. Either that or you got into making bread (is it too soon for lockdown jokes?). There is the hope we can travel somewhere sunny for the holidays this year, so it’s about time a lot of people started working on their summer body, added to the fact that gyms have just re-opened here in the UK over the last few weeks, probably there being a lot of people who are eager to get their workouts in. Over the years fitness has also become somewhat of a lifestyle, with people who started exercising a week ago creating their own fitness Instagram page and every other influencer on social media sharing their workout routines. I bet you know someone who has done or is planning to do some type of exercise event – a though mudder, hike up a known mountain, do a marathon or half marathon. Physical activity is everywhere.

But how did exercise become so famous and is this fame warranted? You may be thinking, “What a click-bait title you came up with. What do you mean by ‘wonder pill’? Exercise is tiring, difficult and boring. It’s only for meatheads and professional athletes. I’ve got better stuff to do with my life, more important stuff”.

There is a lot to unpack there made up person that is meant to represent the reader, but convincing you of the benefits of exercise and why you should be doing it is exactly my aim here. To start, let me clarify a couple of terms I have used so far. Even though they are often used interchangeably, physical activity and exercise do not mean the same thing.

Physical activity: “any bodily movement produced by the contraction of skeletal muscles that results in a substantial increase in caloric requirements over resting energy expenditure” (Thompson, 2014).

Exercise: “type of physical activity consisting of planned, structured, and repetitive bodily movement done to improve and/or maintain one or more components of physical fitness” (Thompson, 2014).

You will understand soon why I present this distinction.

Even though exercise appears to have become increasingly famous in the last few years, we still need to talk about it as there is still a lot of people who don’t do it. Guthold et al. (2018) looked at worldwide trends on physical activity between 2001 and 2016. In their paper, insufficient physical activity defined as adults not meeting WHO recommendations 2010 on physical activity for health (at least 150 min of moderate intensity, or 75 min of vigorous intensity physical activity per week). The global percentage of people performing insufficient physical activity amongst all countries was 27.5% (Guthold et al, 2018). That’s almost 30% of everyone in the world not doing enough exercise. Even though that doesn’t appear to be a lot, it is a global average, with some countries presenting percentages of almost 40%, such as Latin America and Caribbean countries and overall high-income countries, with the trend being towards rising with the passing of the years (Guthold et al. 2018). Adding to this, there is also the problem that healthcare professionals are often not aware of how much exercise is recommended we do in order to optimize our health. Looking at my own healthcare corner, only around 16% of physiotherapists in UK (Lowe et al, 2017), 10% of physiotherapists in Australia (Freene, 2017), and between 4-6.8% of physiotherapists in Israel (Yona et al., 2019) fully knew the respective national physical activity guidelines.

How I looked learning this. I know we can do better.

But why should we care about exercise? What do we gain from it?

To start with we have the obvious benefits of reducing fat (Oja et al, 2015; Miller et al, 2013; Wewege et al, 2017; WHO, 2020), increasing your muscle mass (Schoenfeld and Grgic,  2018; Schoenfeld et al, 2017; WHO, 2020) and muscle strength (Miller et al, 2013; Schoenfeld et al, 2017; WHO, 2020). However it’s not just about how you look. One of the critiques I have towards a big part of the fitness industry is always focusing on aesthetics. Yeah it’s cool and beneficial to have big muscles and look lean, but that continues the stereotype that regular physical exercise is for meatheads and is a disservice to what exercising can do for you.

Regular exercise also takes care of your heart and lungs, improving you blood pressure (Cornelissen and Smart, 2013; WHO, 2020), and how much oxygen your lungs can take in and transfer to the body ( Miller et al, 2013; Oja et al, 2015; Sultana et al, 2019; WHO, 2020). And going completely against the stereotype that exercising is for roid-raging people, there is a significant amount of evidence indicating that exercise offers benefits to your cognitive ability and memory (Blomstrand and Engvall, 2021; Loprinzi et al, 2018; Ludyga et al, 2020; WHO, 2020).

How I feel after going for a run

But the non-athletic benefits of health don’t stop there. Taking the risk of sounding like those Billy Mays’ TV-sales commercials, there’s more.

Research has also indicated that regular exercise reduces the risk of dying in general (usually called all cause-mortality)(Saeidifard et al, 2019), reduces the risk of dying from a heart problem (Oja et al, 2015; Saeidifard et al, 2019) or of your heart having reduced blood flow to itself, medically known as myocardial infarctions (Saeidifard et al, 2019).

Adding to this impressive list, which in by no means exhaustive, a more recent finding indicates that exercising regularly made people less likely to be hospitalized or dying from COVID-19 (Sallis et al, 2021). I don’t know about you, but right now you I’ll sign up for that.

Considering all this, I kindly ask you to engage in a thought experiment. Imagine there was a pill that improved you muscles, made you lose fat, improved how your heart, lungs and brain work, made you less likely to die and have heart problems, as well as decreasing your risk of ending up in hospital due to COVID-19. How much would you be willing to pay for it? What if that pill was free, but for it to have effect you would have to take it most days of the week and preparing it takes between 30min to 1hour and requires a fair amount of physical effort? Still sounds like a good bargain, no? Well, that exists: that is what exercise is.

Hopefully by now I have managed to convince you about how beneficial exercise is. But the question lingers: How much exercise should we be doing to benefit our health? Luckily for you, the World Health Organization has just recently updated their physical activity guidelines, so let’s look at their recommendations.

Children and Adolescents (5-17 years)

In this age group, individuals should do an average of at least 60 minutes of moderate to vigorous intensity exercise per day throughout the week, together with strengthening activities or exercises at least 3 days per week (WHO, 2020).

This would mean activities like brisk walking, playing badminton or tennis, low impact aerobic dancing all the way to playing basketball, swimming laps, jogging and resistance training such as bodyweight (Press-ups, pull ups and similar) or exercising with free weights or resistance machines (Hagerman, 2012).

Adults (18-64 years)

Adults should do at least 150-300minutes of moderate-intensity or 75-150 minutes of vigorous intensity aerobic physical activity, or equivalent combination, per week (WHO, 2020). Adding to this, they should perform muscle strengthening activities of moderate or greater intensity, that involve all major muscle groups, on 2 or more days a week (WHO, 2020).

In simpler terms this would look more or less like this:

  • 25 to 50 minutes 6 days a week of brisk walking, playing badminton or tennis, low impact aerobic dancing, light effort rowing machine or stationary bike (Hagerman, 2012).
  • 15 to 30 minutes 5 days a week of playing basketball, swimming laps, jogging, circuit training, moderate effort rowing machine or stationary bike (Hagerman, 2012).
  • In addition or instead of these, two or more days a week of performing body weight exercises such as push-ups, chin-ups, lunges or exercises using free weights or resistance machines that target all major muscle groups (Hagerman, 2012).

Now, for some of you these recommendations may raise concern or even seem impossible to stick to. The WHO guidelines (2020) also give good news regarding these concerns: a constant message throughout the document, for all mentioned age groups is that any or some exercise is better and still provides benefits when compared to none. Interestingly, and on the same note, one of the changes from the previous guidelines to the current ones is that they also included sections on sedentary behaviour (WHO, 2020). It is recommended that together with trying to the weekly minimums of physical activity, you should also aim to reduce the daily amount of time you spend sitting down watching TV or any other screens, driving or at your work desk (WHO), within any practical or reasonable limits you may have to this.

Remember at the start when I explained the distinction between physical activity and exercise? The guidelines I’ve been quoting name themselves physical activity guidelines. However they recommend physical activity in a way that is structured, done in a somewhat planned manner. That, by definition means it is exercise. The reasoning I’m pointing this out is that even though the evidence suggests that some activity is better than none, if you find yourself struggling to reach your health or fitness goals, I would advise you to review your planning, as it may not be enough.

As this text is already quite extensive, I’ll finish on those notes. If there is anything I would like you to take from the text is this: perform as much exercise as you can within your personal limitations, as some is always better than none, at the same time as you reduce the amount of time you spend sitting. Your health will thank you! And if you have any doubts or concerns about your safety to exercise, consult your nearest friendly doctor or physiotherapist.

When in doubt if you should exercise, think about what Shia Labeouf would tell you

As always, if you found it informative or helpful, share this text throughout your preferred social media platforms. Stay active while you wait for the next one.

References:

  • Blomstrand, P. and Engvall, J. 2021. Effects of a single exercise workout on memory and learning functions in young adults—A systematic review, Translational Sports Medicine, 4(1), pp. 115–127. doi: 10.1002/tsm2.190.
  • Cornelissen, V. A. and Smart, N. A. 2013, Exercise training for blood pressure: a systematic review and meta-analysis.’, Journal of the American Heart Association, 2(1). doi: 10.1161/JAHA.112.004473.
  • Guthold, R., Stevens, G. A., Riley, L .M., Bull, F. C. 2018, Worldwide trends in insufficient physical from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1.9 million participants. Lancet Glob Health, [e-journal], 6, pp. 1077-1086. Available through < https://doi.org/10.1016/S2214-109X(18)30357-7 >.
  • Hagerman, P. 2012. Aerobic Endurance Training Program Design. In: J. W. Coburn, M. H. Malek, eds. 2012. NSCA’s Essentials of Personal Training. Human Kinetics, pp389-409
  • Kovacevic, A., Mavros, Y., Heisz, J.J., Singh, M.A.F., 2017. The Effect of Resistance Exercise on Sleep: A Systematic Review of Randomized Controlle Trials, Sleep Medicine Reviews. Elsevier Ltd, 39, pp. 52–68. doi: 10.1016/j.smrv.2017.07.002.
  • Loprinzi, P. D., Frith, E., Edwards, M., K., Sng, E., Ashpole, N. 2018, The Effects of Exercise on Memory Function Among Young to Middle-Aged Adults: Systematic Review and Recommendations for Future Research, American Journal of Health Promotion, 32(3), pp. 691–704. doi: 10.1177/0890117117737409.
  • Lowe, A., Littlewood, C., McLean, S., Kilner, K. 2017. Physiotherapy and physical activity: A cross-sectional survey exploring physical activity promotion, knowledge of physical activity guidelines and the physical activity habits of UK physiotherapists’, BMJ Open Sport and Exercise Medicine, 3(1), pp. 1–7. doi: 10.1136/bmjsem-2017-000290.
  • Ludyga, S., Gerber, M., Pühse, U., Looser, V. N., Kamijo, K. 2020, Systematic review and meta-analysis investigating moderators of long-term effects of exercise on cognition in healthy individuals, Nature Human Behaviour, 4(6), pp. 603–612. doi: 10.1038/s41562-020-0851-8.
  • Miller, C. T., Fraser, S.,F., Levinger, I., Straznicky, N.,E., Dixon, J.,B., Reynolds, J., Selig, S.,E. 2013, The effects of exercise training in addition to energy restriction on functional capacities and body composition in obese adults during weight loss: A systematic review, PLoS ONE, 8(11). doi: 10.1371/journal.pone.0081692.
  • Oja, P., Titze, S., Kokko, S., Kujala, U. M., Heinonen, A., Kelly, P., Koski, P., Foster, C. 2015. Health benefits of different sport disciplines for adults : systematic review of observational and intervention studies with meta-analysis’, British Journal of Sports Medicine, pp. 1–8. doi: 10.1136/bjsports-2014-093885.
  • Saeidifard, F., Medina-Inojosa, J. R., West, C. P., Olson, T.P., Somers, V. K., Bonikowske, A. R., Prokop, L. J., Vinciguerra,M., Lopez-Jimenez, F. 2019. The association of resistance training with mortality: A systematic review and meta-analysis, European Journal of Preventive Cardiology, 26(15), pp. 1647–1665. doi: 10.1177/2047487319850718.
  • Sallis, R., Young, D. R., Tartof, S. Y., Sallis, J. F., Sall, J., Li, Q., Smith, G. N., Cohen, D. A. 2021. Physical inactivity is associated with a higher risk for severe COVID-19 outcomes: a study in 48 440 adult patients. British Journal of Sports Medicine,1-8, bjsports-2021-104080. https://doi.org/10.1136/bjsports-2021-104080
  • Schoenfeld, B. and Grgic, J. 2018. Evidence-based guidelines for resistance training volume to maximize muscle hypertrophy, Strength and Conditioning Journal, 40(4), pp. 107–112. doi: 10.1519/SSC.0000000000000363.
  • Schoenfeld, B. J., Grgic, J., Ogborn, D., Krieger, J. W. 2017, Strength and Hypertrophy Adaptations Between Low- vs. High-Load Resistance Training: Systematic Review and Meta-Analysis, The Journal of Strength and Conditioning Research, 31(12), pp. 3508–3523.
  • Sultana, R. N., Sabag A., Keating, S.E., Johnsons, N.A., 2019 The Effect of Low-Volume High-Intensity Interval Training on Body Composition and Cardiorespiratory Fitness: A Systematic Review and Meta-Analysis, Sports Medicine. Springer International Publishing. doi: 10.1007/s40279-019-01167-w.
  • Thompson, P. 2014. Benefits and Risks Associated with Physical Activity. In: Allen, K., Bryant, M.,S., Anderson, M., Buckley, T., Balady, G., Castellani, J., Berry, M., Costanzo, D., Blissmer, B., Deschenes, M., Bonzheim, K., Donnelly, J., E., Braun, B., Fernhall, Bo., Figoni, F., S., Hand, G., Fisher, N., Headley, S., Fulco, C., Jackson, J., Garber, C.,E., Kenefick, R., Garner, A., Kohn, C., Gordon, N., Kohrt, W., Hall, E., Lee, ., Marquez, D., X., Pate, R., McInnis, K., Preuss, R., Morey, M., Schmitz, K., Mottola, M., Sharoff, C. Muza, S., Simmonds, M., Nixon, P. Thompson, P.,D., O’Neil, J.,R.,2014. ACSM’s Guidelines For Exercise Testing and Prescription. Philadelphia: Wolters Kluwer – Lippincott Williams & Wilkins, p. 3.
  • Wewege, M., van den Berg, R., Ward, R.E., Keech, A. 2017. The effects of high-intensity interval training vs. moderate-intensity continuous training on body composition in overweight and obese adults: a systematic review and meta-analysis,  Obesity Reviews, 18(6), pp. 635–646. doi: 10.1111/obr.12532.
  • WHO guidelines on physical activity and sedentary behaviour. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO.
  • Yona, T., Ami, N., B., Azmon, M., Weisman, A., Keshet, N. 2019. Physiotherapists lack knowledge of the WHO physical activity guidelines. A local or a global problem? Musculoskeletal Science and Practice. Elsevier, 43(February), pp. 70–75. doi: 10.1016/j.msksp.2019.07.007.

The Pre-Socratics part 1: Tales of olives and beans

We finally start our journey into the second major topic I intend to dive into in this website – Philosophy. If you’re reading this, you’re probably not someone who immediately rolled your eyes and thought of a thousand better things that you could be doing than reading about philosophy. I expect that to be the reaction of the general population to this topic. Sadly philosophy has not been the best at maintaining a positive public image and is mostly seen as this esoteric spouting of academic jargon by some old men sitting on leathery chairs in a room that smells of cigars and whisky – or coming as the result of a supposed “enlightened state” you achieve by smoking copious amounts of weed. We’re still waiting on scientific research to back that one up.

What I propose to do is try to fight against those notions and share with you how some of the mainstream ideas still present in our society developed, with a particular focus in the development of epistemology – the branch of philosophy which studies what constitutes knowledge and how it can be obtained (Sim, 2002).

Where shall we start then? As with most things, it makes sense to start from the beginning. Usually, it is good practice to start any philosophical text with definitions, as it is important we’re all talking about the same thing. However in this particular case I will jump that step, as the definition of and the word ‘philosophy’ itself were not present when it first started being practiced. But don’t worry, it will come up later in the midst of a religion that forbids the sinful legumes that are beans. Yes, that wasn’t a typo. If that grabbed your attention, stick around to find out more.

Due to the difference in the impact their ideas had, often scholars will divide the early history of ancient philosophy into the pre-socratics and then Socrates (Adamson, 2014; Russell, 1946). This is a hot topic among professional philosophers, but as I am no specialist in the area, I will follow this division due to how frequently it is used currently.

Once upon a time, in the sixth century B.C., in a region called Ionia (present day Turkey) there was the O.G. of philosophy: Thales of Miletus (Adamson, 2014; Russell, 1946). Most of the early explanations about the world until the sixth century BC were supernatural and or theological – most phenomena and events in the world were said to be caused by the action of gods or other otherworldly entities such as Destiny. Thales was not satisfied with these explanations and tried to achieve answers based on logical analysis of nature (Adamson, 2014). He believed that the world could be understood through knowledge and this knowledge then applied in practical ways. If this doesn’t show the hallmarks of a scientific mind, I don’t know what will.

Something that is important to answer at this point is that considering that Thales’ views are almost scientific, how does that connect to philosophy and make him be recognized as the first philosopher? The separation of philosophy and science is a recent one (Adamson, 2014; Russell, 1946), science and scientists branching out of philosophy and philosophers. Thus at the time, the characteristics we currently associate with scientists, were the ones that defined philosophers. Personally, I think this separation should never be a full one, as any modern day scientist has (or should aspire to have) at least a portion of a philosopher inside them.

Returning to Thales, there are two commonly told stories about him and his attempts to understand the world through knowledge. The first one tells us about how Thales, through contact with Babylonian astronomers, was able to predict a solar eclipse in 585 BC (Adamson, 2014; Russell, 1946) – pretty amazing considering this was way before Google. Here we can see how, akin to a modern scientist, Thales would apply knowledge to understand and somewhat predict natural phenomena. We can also thank him for introducing geometry, which he learned from the Egyptians, to Greece (Russel, 1964). But Thales didn’t stop there. He was criticized by some due to being somewhat poor as an argument for the uselessness of spending his days thinking about things as philosophers often do (Russell, 1946). However, Thales was not one of those head-in-the-clouds philosophers. No, he was a hustler and determined to show the value of logical understanding of the world. Using his knowledge of astronomy and weather conditions, while it was still winter, he was able to predict that in the coming harvest season there would be a great harvest of olives. With this knowledge he went and placed most of the little money he had into hiring all the olive presses (used to make olive oil) in Miletus at a low price, because in winter no one bid against him. Coming the harvest season and the abundant harvest of olives, just as Thales predicted, the olive presses were highly sought after. As he had the monopoly over the olive press market, he was able to rent them out at the price he desired and was able to make a fortune (Adamson, 2014; Russell, 1946).

Thales investing in olive presses knowing they would be needed come harvest season

Besides showing the practical applications of knowledge, Thales also started the longstanding tradition of trying to understand the essence of the universe – what is the world and all things in it constituted of? His hypothesis was that water was the most fundamental of substances, all the others being formed of it (Adamson, 2014; Russell, 1964). It is speculated that his argument came from him seeing the importance of water for different forms of life (Adamson, 2014).

Another of Thales known hypothesis was that ‘everything is full of gods’. This came from his observations of magnets and their ability to move iron. This was because at the time, motion was associated with having a soul, which itself is divine. Thus, even something devoid of life such as a magnet, has a piece of divinity in it (Adamson, 2014).

These two arguments may seem ridiculous considering our current knowledge. However, their value, and what identified him as the first philosopher, comes from the systematic way Thales reached said arguments. There is a tentative approach to a theory based on arguments originating from observations, as opposed to an explanation based solely on the whims of gods. Sounds familiar? Thales is basically applying the process of induction – a modern approach to epistemology where a theory is generated on the basis of empirical observations (Bowling, 2014; Sim, 2002).

The following two pre-socratic philosophers, Anaximander and Anaximenes, also hail from Miletus and together with Thales form a group that is known as the ‘Milesian school’ (Adamson, 2014; Russell, 1964). In a way following from Thales cosmogony (study of the origins of the universe) both Anaximander and Anaximenes expressed theories about the fundamental substances that constituted the universe and everything in it.

Anaximander argued that everything in the universe emerged from single primal substance he called something in the lines of “the infinite” or “the indefinite” (from the greek apeiron, “that which has no limit”) (Adamson, 2014). He believed this substance surrounded the whole universe and that all other substances emerged from it, and then also transformed into and destroyed each other (Adamson, 2014; Russel, 1964). Although we now know better, there was logic to Anaximander’s ideas. The reason why the primal substance that constituted the universe had to be something undefined as opposed to something like water or fire comes from a notion that is common between a lot of pre-socratic philosophers: a cosmic balance maintained by opposed forced in nature (Adamson, 2014; Russel, 1964). If the primal substance that is present throughout the whole universe was something like water, then in their mind the universe would became gradually wetter and colder. Or if instead, the fundamental substance was fire, the universe would gradually become hotter and everything would burn. Thus, by having an indefinite, neutral substance from which all other emerge, there is a continuous opposition that would maintain the balance (Adamson, 2014; Russel, 1964). Anaximenes, following a similar reasoning, but for him the fundamental substance was air (Adamson, 2014; Russel, 1964). This was due to the observation that if most living things stopped breathing, they would perish. Thus, he made the connection that the soul must be made of air (Adamson, 2014; Russel, 1964). In addition to this, the characteristic of air being fluid, for Anaximenes explained the fluidity of nature, with air turning into other substances by becoming thinner and hotter – the case of fire – or becoming thicker and colder – the case of water and earth (Adamson, 2014; Russel, 1964).  He is also responsible for first coming up with the idea that earth is a flat cylinder, basically making Anaximenes the first flat-earther (Adamson, 2014; Russel, 1964).

I would like to see what Anaximenes thinks of this version of Earth

For the next pre-socratic philosopher, despite the historical clock still indicating sixth century BC, we will be moving north from Miletus to Colophon, still in what is present day Turkey. There was the birthplace of the poet Xenophanes (Adamson, 2014). His ideas were not in the same lines as the philosophers we looked at so far, but they were still revolutionary for the time. He mainly contributed with the thoughts that the gods are different from humans, that there is only one God and questioning what can really be known (Adamson, 2014). For those who don’t know, before Thales came along and tried to think critically about things, most of the explanations about the world came from the poets, in particular Homer and Hesiod and their respective texts, the Iliad and Theogony (Adamson, 2014). These texts are where we find the description of the greek pantheon of gods as we know it and how the universe was created. Basically the equivalent of a sacred text. In these texts, the gods were not only described as having human form, but also being born from parents, wearing clothes and engaging in all sorts of promiscuous activities (Adamson, 2014). If there is something Zeus is known for, is not being able to keep it in his trousers.

Greek mythology 101

Xenophanes criticized this, saying that humans were not made in the image of gods, but that instead these gods were made in the image of humans (Adamson, 2014). Xenophanes still believed in a God, but he argued that it would be worthy of reverence and as be unlike humans as possible, but always in a better way (Adamson, 2014). Thus, in typical greek fashion, reason being the only characteristic of humans that is worthy of being called divine and the one that sets them apart from animals, Xenophanes’ God is a good that does nothing but think and is incomparable to humans in both body and mind (Adamson, 2014). Xenophanes also criticized the idea of worldly phenomena being gods or caused by them. The rainbow is not some goddess named Iris, it’s just some clouds with colours on it. The sun is a god named Helios? Nonsense, it is just fire gathered in a big ball (Adamson, 2014). Here we can perceive an interesting mixture of a theistic world view with a more critical perspective often associated with atheism. But this was not his only revolutionary idea. He looks at all the affirmation he and others have made about the gods and the world, and stated that even if what they believe ends up being true, no one can really know for sure (Adamson, 2014). Philosophically, this is a very important distinction, particularly for epistemology, between what we believe and what we can actually know. It is important to understand that these two things are different, and Xenophanes was the first one to openly state this issue and doubting his own reasoning. This scepticism can almost be argued to kick-start epistemology and will later be a prominent characteristic of Plato (Adamson, 2014).

The last pre-socratic philosopher we will be covering in this text will be Pythagoras. I’m really thankful if you kept with me for this long – be honest, it was the curiosity about the sinfulness of beans that kept you going, wasn’t it? There are still some philosophers left before Socrates, however, I want to strike a balance between explaining some detail with still remaining a non-exhaustive overview of philosophy. Surprise! There will be a part 2 to pre-socratic philosophers.

Back on topic, you’ve probably heard of Pythagoras, if not at least through his famous theorem – I apologize for any flashbacks to math classes, if it wasn’t your thing. Pythagoras was born in Samos, an island of the same coast of Turkey from where the previous philosophers were from. Before he started coming up with mathematical theorems, he founded a religion, of which the followers were known as ‘Pythagoreans’ (Adamson, 2014). This religious order was based on Pythagoras beliefs about the world and how one should act in it. It even had rules that its members had to follow. Can you guess what was the first rule created by the religious order of a mathematical genius? The first rule was “To abstain from beans” (Adamson, 2014; Russel, 1964). Yes, this is where this comes up and there is never a really concise explanation for this.

There is a whole section of the interned dedicated memes of beans. Maybe this was the evil Pythagoras was trying to warn us about

One important aspect about Pythagoras was this man was surrounded in myths and legends. His followers were divided in two types: the ones interested in his esoteric ideas and the ones interested in his mathematical skills (Adamson, 2014). The more esoteric Pythagoreans are the likely responsible for these legends, probably as a way of validating their religious beliefs and further spreading them. Pythagoras probably helped to this as he supposedly saw himself as semi-divine, which spurred up stories of him being the son of a god, either Apollo or Hermes (Adamson, 2014). There are also the legends that he had a thigh made of gold and could talk to animals (Adamson, 2014). Sound more and more like a god among humans – or someone with a very active imagination. Another myth about Pythagoras that leads to another of his religious tenets was that he walked by some people beating up a dog and supposedly Pythagoras heard the voice of a deceased friend coming from said dog (Adamson, 2014; Russel, 1964). Here we can see that Pythagoras believed in the transmigration or reincarnation of souls: souls leave their bodies upon death and go into another body, even of different species (Adamson, 2014; Russel, 1964). This may sound quite nonsensical to some, but it was one of the first recorded instances of the theory of dualism of body and soul (Adamson, 2014) which will influence later philosophers such as Plato and even Descartes.

It was also through Pythagoras that the word ‘theory’ acquired its modern meaning (Russel, 1964). Initially a word associated with a mystic tradition called Orphism, it meant “passionate sympathetic contemplation”, with the one undergoing it assuming something akin to a godlike state (Russel, 1964). To Pythagoras, this “passionate sympathetic contemplation” was an intellectual state and obviously, mathematics was involved in it. However, to philosophers influenced by Pythagoras, it retained a proportion of divine revelation (Russel, 1964). Here we start seeing the gradual formation of the association between intellectual pursuits and the divine, which will be present in many philosophers. This is reinforced by the belief that the soul was separated from, and thus, difference in essence from the body. The body fades away, but soul remains throughout multiple reincarnations. Thus the soul is made of something everlasting – something divine. There was also fact that at the time, mathematical knowledge was associated with a certainty that was above the knowledge obtainable through the senses or intuition (Adamason, 2014; Russel, 1964). As previously stated, if the world of sense did not match the insights obtained through the contemplative knowledge of mathematics, then it was the world of sense that was wrong (Russel, 1964).

There are some that even attribute to Pythagoras the saying “all things are numbers” (Adamason, 2014; Russel, 1964). It can be argued that this was not meant literally, but as an affirmation of the presence of mathematics in all things in nature (Adamason, 2014; Russel, 1964). A ‘4’ is something that is present in the real world – one can have 4 apples – but doesn’t really exist as no one sees ‘4’s going around in the street. And it is a concept that is transversal throughout the world and throughout time So it is something abstract and everlasting, but that is still underlying in everything we can experience in objective reality – sounds divine, right?

Russell (1964) expressed that he believed mathematics to be the source of both a belief in an eternal and exact truth, and the existence of an intelligible world beyond the senses – a divine truth. Thus, mathematics in his modern form, as a demonstrative, deductive argument starts with Pythagoras (Russel, 1964). This perspective to mathematics made it often be argued as the ultimate intellectual pursuit, because it would allow humans a connection with the divine (Adamason, 2014; Russel, 1964). Because of these ideas and his approach to mathematics, he also responsible for the influence that mathematics will have from there onwards in philosophy and logic (Russel, 1964; Adamson, 2014), and through this he will be seen to have a great influence on Plato (Russel, 1964).

Still relating to mathematics, at the time, the Greeks, and Pythagoras by extension, viewed geometry as axioms, generally applicable ideas that are, or deemed to be, self-evident, from which theorems are derived deductively (Russel, 1964).We have to place another important epistemological marker here, as Pythagoras is describing the process of deduction – a modern approach to epistemology where theory is developed from a general idea through reasoning, this theory being tested afterwards (Bowling, 2014; Sim, 2002). But, despite all his love of numbers and their divine nature, there is something that we have been wrongly told: it is very likely that Pythagoras did not himself come up with the famous theorem. Historian often attribute this to the pythagoreans who followed him and it possibly originated after Pythagoras was already dead (Adamason, 2014; Russel, 1964). Shocking, I know. You can’t even fully trust maths textbooks these days.

And now we come to the last great contribution of Pythagoras to philosophy. Pythagoras was the first person to call themselves a philosophos, meaning “lover of wisdom”, with Sophia being the greek word for ‘wisdom’ (Adamson, 2014). A lot of you probably learned that detail in school, but as I said at the start, a good practice in philosophy is to start with definitions. Well, it was not the start of this text, but we are defining it at the start of this series of texts, so it kind of counts, right?  Simply that is how the term philosophy first came up. Philosophy will basically mean “the loving of wisdom” and obviously if you love something, you go after it. So if you like learning, you probably have a bit of a philosopher in yourself as well. Hopefully, this text has contributed to your leaning. You now know about how it all started with Thales and those who followed him, until Pythagoras came up (or not) with his theorem and hate of beans; how some ideas by these philosophers were so influential to humankind that they still last from the sixth century BC all the way to present day: the attempt of understanding the world through logic, there being a fundamental substance that constitutes everything in the universe, the rejection of the gods as being the cause of everything, and important epistemological concepts such as inductive and deductive reasoning, and the discussion of what can actually be known. But we are only starting. I didn’t plan it initially, but this will continue in part 2 of pre-socratic philosophers. If you feel you’ve learned something and want to show off your love of wisdom, please share this text all over social media and see you in part 2.

References:

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

Bowling, A. Research Methods in Health – Investigating health in health services. 2014, fourth edition. Open University Press. Berkshire, England

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

Sim, J., Wright, C . 2002. Research in Healthcare – Concepts, Designs and Methods. Second edition. Nelson Thornes Ltd. Cheltenham, United Kingdom