“But in the current digitized world, trivial information is accumulating every second; preserved in all its tritness, never fading, always accessible; rumors of petty issues, misinterpretations, slander. All junk data preserved in an unfiltered state, growing at an alarming rate, it will only slow down social progress. The digital society furthers human flaws and selectively rewards development of convenient half-truths…The untested truths spun by different interests continue to churn and accumulate in the sandbox of political correctness and value systems. Everyone withdraws into their own small gated community, afraid of a larger forum; they stay inside their little ponds leaking whatever “truth” suits them into the growing cesspool of society at large. The different cardinal truths neither clash nor mesh, no one is invalidated but no one is right. Not even natural selection can take place here. The world is being engulfed in “Truth”. And this is the way the world ends. Not with a BANG, but with a whimper.”
The Colonel, from Metal Gear Solid 2: Sons Of Liberty
Being able to quote an overly dramatic fictional AI military general from a 2001 PlayStation 2 classic video game in a physical therapy blog/rant is just one of the many talents I bring.
I think I have been spending too much time on Instagram. Too many reels, too many posts, too much information. The intensely frustrating and disturbing thing is that for any given question in musculoskeletal healthcare, fitness, or nutrition, you can find any answer you want on social media. Maybe it is a pet peeve of mine, but posting obviously uncritical, non-rigorous content really winds me up. And it’s even worse when unqualified, non-medically trained people provide what is clearly medical advice. These people have no idea how deeply unserious they are.
It’s easy enough to browse social media and find conflicting opinions on any question you might want to ask. Will deadlifts make your spine explode or bomb-proof your core? How can you fix your posture? Does posture matter at all? Should we avoid meat? Should we only eat meat? What actually causes back pain? What can a misaligned spine cause? Anxiety? GI distress? Depression? Foot pain? Are eggs good for you? Just the whites? How could you possibly throw out the yolks??? I wanted to highlight some conflicting posts here, but to avoid the risk of seeming like I am picking on anyone or cherry-picking outrageous examples, I won’t. Just go do your own research.
The Spell Of Mathematics
How do we know what is true? What does truth even mean, in the context of healthcare and fitness? How can we really be sure of anything at all? The study of epistemology is the study of knowledge itself; what it is, what constitutes it, and how we get it. And while the value of internal debate among philosophers on this topic may seem remote, deciding what is true is of critical importance in medicine, especially when there are seemingly simple questions that have complex answers.
With the question of health in general and on topics in musculoskeletal healthcare and nutrition specifically, arriving at the truth is more difficult than one would think. In addition to debating what the facts of the case are, there is disagreement on how to get said facts. Thus far, the best knowledge-producing enterprise we have for getting these facts has been science. The corresponding movement to base our medical knowledge on the fruits of science has been appropriately called science-based medicine or evidence-based practice. The basic tenet of these philosophies is simple: we ought to provide medical care that is supported by the best available science we have. That is not to say that science is perfect, or doesn’t make mistakes, or should be trusted blindly. Anyone that has read a research paper and tried to understand it knows this. But any criticism of the scientific process applies to the alternatives just as much, if not more. Bias, misunderstanding, and ulterior motives are present in all human endeavors, but especially so when someone is selling you a course, an ebook, or a supplement.
Rejecting evidence-based medicine, underestimating the value science, and engaging in pseudoscientific practices in physical therapy brings us to an epistemological black hole: I fear that if we cross the event horizon, we will be transformed into something unrecognizable and we will be confined there with no way out. That is a barrier we shouldn’t cross. To answer the types of questions we want to ask, we need to speak the language of science, i.e. statistics. If someone isn’t doing this, why bother listening?
Shifting Careers
One reason I am shifting careers and moving to biostatistics has to do with my perception of physical therapy practice. It just seems like a good percentage of us are not doing what we should be doing. A study by Zadro et.al. from 2019 investigated this. The central question (and literal title of the paper) was “Do physical therapists follow evidence-based guidelines when managing musculoskeletal conditions?” And the answer, unfortunately, was essentially “not really.” Only about half of physical therapists assessed chose to follow evidence-based guidelines. A little less than half of therapists were providing treatments that were explicitly not recommended by guidelines.
“Our results suggest that physical therapy treatment choices for musculoskeletal conditions are often not based on research evidence. There was extensive use of not-recommended treatments and treatments without recommendations; for some conditions, treatments that were not recommended or had no recommendation were more common choices than recommended treatments…The high percentage of non-evidence-based treatment choices in our review suggests that referring patients with musculoskeletal conditions for early physical therapy—without emphasizing the importance of the type of non-pharmacological care they receive—may be unwise.”
When friends or family ask me for musculoskeletal advice, I am honestly hesitant to recommend going to therapy, and THIS is why. If we are not basing our treatments on evidence, what in the world are we doing?
Zadro J, O’Keeffe M, Maher C. Do physical therapists follow evidence-based guidelines when managing musculoskeletal conditions? Systematic review. BMJ Open. 2019 Oct 7;9(10):e032329. doi: 10.1136/bmjopen-2019-032329. PMID: 31591090; PMCID: PMC6797428.
Physical Therapy Evidence 