Let's Get Critical

Most therapists I've run into are pretty solid critical thinkers, capable of examining things from a variety of perspectives before jumping headlong into shallow water. Unfortunately, there is a not-too-silent minority of our community that continues to grasp at methods of assessment and treatment that not only aren't consistent with available evidence, they are in direct conflict with the laws of nature and just plain common sense!

I always look forward to a great debate like the one mentioned in an earlier post, but enjoy participating in one even more! The trouble is I find myself often reducing my argument to the level of "Because my view just makes more sense than yours" reasoning that simply doesn't wash with most people. This kind of logic, among others, often irritates and sometimes insults otherwise well-meaning (albeit misinformed) individuals.

Wouldn't you know it but there are actually rules of engagement that can help you get your point across without alienating your fellow coworker or boss. They are brought to us by the late scientist Carl Sagan who offers his criteria for solidifying your logic.

1. Wherever possible there must be independent confirmation of the facts.
2. Encourage substantive debate on the evidence by knowledgeable proponents of all points of view. Arguments from authority carry little weight (in science there are no "authorities").
3. Spin more than one hypothesis - don't simply run with the first idea that caught your fancy.
4. Try not to get overly attached to a hypothesis just because it's yours.
5. Quantify, wherever possible.
6. If there is a chain of argument every link in the chain must work.
7. "Occam's razor" - if there are two hypothesis that explain the data equally well choose the simpler.
8. Ask whether the hypothesis can, at least in principle, be falsified (shown to be false by some unambiguous test). In other words, it is testable? Can others duplicate the experiment and get the same result?

There is certainly a sense of balance we can achieve with respect to our pursuit of gold standards of assessment and treatment. In fact, one of my favorite instructors stated "Nothing is ever proven; only supported."

Here are some questions to ponder the next time you face an argument over a clinical issue: Can you be an evidence-based practitioner without becoming an automaton? Conversely, can you explore creative treatment options without becoming a faith healer? This is an exciting time for our profession. Keep honing your skills and take a critical look at your approach to clinical problems. You may not be the next Carl Sagan, but the exercise will sure do us some good!

A Great Debate

I recently listened to a spirited debate on the PT Journal Podcast regarding two approaches to classification and manipulation for LBP. I strongly encourage you to download the file or subscribe to the podcast and listen for yourself. The debaters Timothy Flynn, PT PhD, OCS, FAAOMPT, and Christopher Maher, PT, PhD brought out some very salient points regarding the assessment and treatment of mechanical low back pain.

To be honest, I had to listen to the debate multiple times to pick out some of the really strong take-home messages that emerged from the discussion. While the debate was focused on the assessment and management of LBP, it had me thinking more rigorously about how these themes could apply to other aspect to our practice. In no particular order of importance:

• The widespread use of the term "nonspecific" low back pain is inadequate and misleading. It would be analogous to our medical colleagues using the words "nonspecific" abdominal pain and contributes to further confusion regarding accurate diagnosis and management.

• There is a need to develop standardized clinical practice patterns and a unified language with respect to the dosage and modes of manual therapy we deliver to our patients.

• There is still considerable variation between highly trained individuals regarding the classification, assessment, and management of mechanical low-back pain.

You can download the link by right-clicking here and saving to your hard drive.

I hope you will download this debate and continue to reevaluate your methodology with respect to evaluation and management of not only low back pain, but other complex conditions as well. Our aim as orthopedic therapists should be to continually elevate our standards of practice. Take care and talk to you soon!