………..continued from last week…..
see part 1 here
This week’s blog highlights the somewhat fragmentary feel of the day. Charting the evolution of Evidence Based Medicine in physiotherapy was a piece of cake compared to some of what we tried to get our heads around. Amongst the speakers were different groups: practising physios, neuroscientists, and philosophers. These different groups are working with very different material, in very different spheres, and how they are related is not always instantly obvious, but they are united by a kind of substantial enthusiasm for forging new paths ahead in their various fields, and it feels like if we wait awhile, and keep watching, something new might just emerge.
At lunchtime I visited a Simon Starling Exhibition down the road. This is a model of a hugely magnified silver particle from a Victorian photograph.
The philosophers introduce themselves
Rani Lill Anjum and Stephen Mumford are the philosophers working on the Cause Health project (into causation, complexity and evidence in health sciences.) I confess I had no idea that ‘philosopher’ as a job title had persisted beyond the age of Ancient Greece, but there are professional philosophers and to my delight some of them have become associated with the manual therapy professions. Rani and Stephen have written a neat little volume on causation. I’ve read chapter one and it hasn’t lost me yet.
Finding an alternative to EBM
What’s causation got to do with anything? It might sound complicated and irrelevant and best left to the philosophers, were it not for the fact that it might help to explain the problems involved in research and evidence for osteopathy and other manual therapies. Yes, these wonderful people are trying to show that EBM is not the only scientific option in medicine, and to suggest an alternative foundation for the current Hume-based framework of causation, in which the same cause always gives the same effect. In Hume’s world, things often only work well and predictably in ideal conditions (and patients do not constitute “ideal conditions”, as we all know too well.) This is why the group study cannot be applied to the individual, because it fails to take into account the causative mechanism within the patient (remember the smashability of the glass). And so this is why RCTs don’t always work that well for unexplained medical symptoms like pain and depression. Incidentally, these kinds of symptoms constitute 30% of GP consultations and must add up to worlds upon worlds of suffering and discomfort.
What they have embarked upon does not seem a trivial exercise, and I doubt you’ll be able to march into the ASA office armed with your philosophy textbook just yet. Rani and Stephen explained that while EBM is hard and objective, and difficult to criticise, the person-centred approach can be too easily dismissed. (Don’t we know it!). They claim that holistic approaches have been seen to work in practice but are hard to explain in theory. And this is the challenge they have seem to have set themselves.
Let’s all embrace dispositionalism
The alternative foundation, or philosophy, that they suggest, is called “dispositionalism”. I don’t know exactly what dispositionalism is yet, but I am all for it. It embraces context-sensitivity, individual variations and tendencies. It is all about looking at the internal characteristics, (or dispositions, I suppose), to explain things. This approach works better for patients who have medically unexplained symptoms like headache, or fatigue. It allows us to see causal factors as interconnected and interacting with other factors, in nonlinear ways. In a nutshell, it allows us to treat every patient as different. Hooray!
Let’s use top down approaches
If we change our ideas of causation, then person-centred high level interventions can also be regarded as a causal influence. We can see that causation can be top down, not just bottom up. Rather than seeing that everything at the coarser physical level determines everything else – which leads you, for example, to treat depression with pharmaceuticals because you assume that altered brain chemistry is the cause of the depression – it allows us to consider that higher can influence lower. e.g. your unresolved childhood trauma or sense of purposeless in life is the cause of your altered brain chemistry. They even quoted someon called Kirkengen who asserts that childhood sexual abuse can cause dental problems and allergies. It gives us license to approach symptoms through lifestyle changes and psychological interventions. And it helps us to explain and justify what we do with our patients. Hooray again!
Emergence emerges as a theme
But we need to show that higher-level phenomena are real and can have an influence. And we do this through another theory – emergence. I know, I know, another long word, another theory. I’m trying to make it simple, but the theory behind this stuff is just not that simple to put in words.
What is emergence?
Emergence has been around for a while but it not yet well-respected, being seen as too “spooky and magical”. I personally think of it as “the whole is more than, and different from, the sum of its parts”. So, if we add two elements together (e.g. hydrogen and oxygen), the process of bonding can change their causal power. Instead of starting fires (as hydrogen and oxygen would separately), these two elements have turned into another substance, (water – for the scientifically-challenged), and can now put out fires. There has been a transmutation of a sort. Emergence is fashionable in our world at the moment, and David Butler includes a section comparing emergent and linear processes on his Explain Pain course. I’m still not quite sure how emergence proves the existence of high level phenomena and justifies their use as interventions, but bear with me. I’m on a steep curve.
Physios in Practice argue in favour of subjectivity, anecdotes and being human
Following these densely intellectual lectures filled with words like ontological, dispositionalism, emergence, reductionism and empiricism, we came back to earth a bit, and heard from a couple of practising physios, Neil Maltby and Matthew Low. These are the people at the coalface. Neil always concludes his Becoming More Human blog with the evocative exhortation to “Be more human. Be less robot”, at which point without fail I am compelled to sing the Killers’ classic hook “Are we human, are we dancers?” (Thus leading me to wonder if I am indeed a human being with free will, or am in fact a programmable robot)
They posed the interesting question: are patients subjects or objects? (Answer: a mysterious blend of both). They spoke of the importance of communication, sense making and rapport in practice. They also made a case for anecdotes being integral to healthcare, and echoed the themes of the morning by asserting that anecdotes should not be relegated to the bottom tier of evidence due to subjectivity and bias. They do agree that case studies and anecdote are prone to subjectivity and bias, but argue that evidence which is removed from the individual has just as many flaws. They argued that subjective measures have sometimes been shown to work better than objective measures (e.g. for athlete’s training responses), and argue that our diagnosis tends to lean by necessity on subjective reports. We were urged to use intuition and emotion, to build a picture of the person, and to refer to all levels of evidence through taking a good history and emphasizing subjective quality.
Take away message of the day: think about properties, tendencies, dispositions in the patient
An example of a property/tendency/disposition
you don’t have to do a huge study to figure out that there’s a 50% chance of a coin landing heads up; you simply need to look at the properties of the coin to work out what is likely to happen.
Tendency is a good word to use, and a good way to think about causation and treatment.
Mick Thacker rounds off the day
As if our minds weren’t already blown enough, the last lecture of the day was given by Mick Thacker. Mick Thacker is a very, very brainy man, who knows a lot about pain science and managed to hold us all spellbound, despite the fact that I, for one, mostly didn’t have a clue what he was talking about. It was obvious, though, that he did know exactly what he was talking about, and so I jotted a few things down as they emerged out of the whirlwind of his mind, as he is clearly a reliable source.
- Stop thinking of c-fibres as ‘pain’ fibres right now! 70% of c fibres have nothing to do with pain – they are post-ganglionic sympathetic fibres.
- Gate theory is flawed – but at least it introduced the idea that the brain has an enabling/inhibiting effect.
- RCTs have absolutely lambasted many modalities used by physiotherapists, such as TENS, acupuncture and mobilizations.
- the so-called pain matrix still lights up in people who have congenital inability to feel pain
- the emphasis on metaphor can be dangerous if you get it wrong
- the “salience network” is about how much you attend to a stimulus
- the “pain centre” of the brain (insula) cannot distinguish between noxious & non-noxious stimuli
- pain is a complex phenomenon and resists attempts to simplify it
He then got really interesting, and started to talk (even faster) about the need to understand qualia (i.e. how do those things happening in our physical nervous system actually turn into what we experience). He thinks emergence and the study of pain might help solve this “hard problem” of consciousness. (I find it hard to explain how thrilled and suprised I am that a career in osteopathy has led me to this lively crew of manual therapists who are exploring the frontiers of consciousness research). He also talked about predictive processing, helped by a huge graphic proclaiming I HAVE A DIG BICK, and reminded us that pain occurs in the “person” and is often experienced as a “loss of agency” – i.e. your pain starts dictating what you can and can’t do, what you want to and don’t want to do.
Mick’s reading recommendations
Surfing Uncertainty by Andy Clark
The Predictive Mind by Jakob Hohwy
He told us that it is actually impossible to dual- or multi-task, talked about dynamic causal modelling (?), talked about the need for us to find our own language and help the patient to find theirs (we talk about that in biodynamics!), and lamented the current trend to repeat slogans like “issues in the tissues” and “pain is in your brain”, as they could be so misleading and damaging to patients.
Whew! If you understood any of that and like it enough to want more, you should probably try to enrol in a pain science MSc at King’s.
So, finally I arrive at the close of what has been one of my most challenging blogs to date. I’m trying to write about things I don’t yet totally understand, but I like this path that CauseHealth are leading us along. I think it’s going to be good for our patients, and good for us. It has an intense energy, and might have the power to change and explain things. And as a profession that is serious about making sure we are doing the best thing for patients, we should make sure we are on board.
Some of the osteopathic contingent then headed off for a drink: from L-R, Professor Stephen Tyreman, Marco Gabutti and Mark Andrews.