Refleksion 1 fra New Zealand: Science

The word ‘science’ means knowledge and derives from the Latin word “Scientia”. Apparently, there seems to be no clear definition of what science is. In my opinion science is the exploration of mechanisms of action by following methodological constructs that eliminate assumptions and illusions of how things work. While I truly appreciate the natural curiosity of human beings, which is the foundation for the development of scientific research as we know it today, I also see how science in healthcare needs to be interpreted in the right context. In his TEDx presentation regarding strength and weaknesses of statistics, Hans Rosling accurately presents some of the thoughts that I have had, and still have, regarding some of the research that has the biggest impact on physiotherapy practice (TEDx, 2010).

The British Medical Journal defines randomised controlled trials as “the most rigorous way of determining whether a cause-effect relationship exists between treatment and outcome” (Sibbald & Roland, 1998). While this may be true, I certainly see areas where this rigorous construct fails the test of clinical practice. However, before explaining how and why that is, my background and experience needs to be outlined.

Upon completion of my undergraduate physiotherapy training in 2014, I took a temporary job in a hospital working with outpatients dealing with issues in the area of orthopaedics and sports. After spending 1.5 years working in a hospital, I moved to private practice where I dealt with a wide array of issues related to the body, but primarily shoulder problems, neck pain and back pain. In my years of practice I have observed that the majority of people seeking care could be treated effectively using management including proper education, correct exercises and adjustments of motions, postures and loads; however, a small (maybe 5-15%), but significant group of people respond very well to manual therapy (joint mobilizations and manipulations). The scientific literature does support the use of manual therapy for some conditions. However, the effects in many conditions seem to be no more beneficial than other interventions. For that reason, evidence-based research may disregard manual therapy. I argue that this is due to an under appreciation of individual data in the scientific construct of golden standard ‘randomised controlled trials’. As only a minority of individuals show major improvements from manual therapy, their data and positive responses ‘drown’ in the statistical abuse of ‘mean values’ and p-values. As a clinician, I would love to see more randomised controlled trials that highlight the characteristics of individual patients who respond both positively and negatively to manual therapy and other interventions. This way science would appreciate ‘the truth’, thus helping to tailor treatment to the individual and not just general recommendations for certain conditions. 

Social media such as Twitter is a platform used by many researchers to share and discuss new research findings and articles which draw their attention. As Twitter draws attention to a lot of researchers, I have personally used Twitter to stay up-to-date with ‘hot’ topics in regard to my profession. However, I have noticed during my years using Twitter that manual therapy appears to be an ongoing topic of discussion. This discussion seems to have divided the profession into two groups, one group which supports the use of manual therapy and another group which disregards manual therapy as an area of importance in physiotherapy. Both groups refer to evidence that supports their bias in relation to manual therapy; almost like ‘manual therapists versus physiotherapists’, even though they are from the very same profession. It seems as though the assumptions are that randomised controlled trials show the absolute truth with no exception. An interesting aspect in these debates is that the scientific method and what it ‘can’ and ‘cannot’ illustrate is never discussed. 

I have chosen to finish this formal contribution with a quote/statement from renowned and respected physiotherapist Geoff Maitland:

“For a theoretical statement to be correct, it must fit the clinical situation. If it does not fit, it is the theoretical statement that must be wrong because the clinical situation cannot be wrong” (Maitland, Hengeveld, Banks & English, 2005, p. 7). 

To acknowledge and appreciate this statement we must not forget the individual participating in research. I would love to know if other health practitioners have had similar thoughts about how individual data may be underappreciated?

References

Sibbald, B., & Roland, M. (1998). Understanding controlled trials: Why are randomised 

controlled trials important? British Medical Journal, 316(7126), 201.

Maitland, G. D., Hengeveld, E., Banks, K., & English, K. (2005). Maitland's vertebral manipulation. 

Oxford: Elsevier Butterworth-Heinemann.

Rosling, H. [TEDx]. (2010, July 20). The good news of the decade? Retrieved from 

https://www.youtube.com/watch?v=OT9poH_D2Iw