Critical Thinking

Merging Humanism and Science to Develop a New Kind of Practice for Pain

Greetings, my name is Eric and I am excited to join the Forward Thinking PT blog.  As a contributor I want to ask questions about where our profession is going and how we are getting there. Rather than waste anytime I want to dive right into what I have been thinking about lately.

Firstly, if one wants to start with the question, “What is best practice?” Typically, one might look towards scientific support to answer this question.  Our field, that of physical therapy, is borne out of the bio-medical model and therefore enjoys a strong relationship to science (or at least it should).  Science based reasoning has a lot of advantages.  Of these, the most important is that ideas, theories, and concepts can be put to the test of observation.

What is not widely discussed is the drawbacks of science.  Science after all can only tell us what has occurred and what is likely to occur given a specific set of determinants.  What it cannot say is what should be or what could be.  These are much more difficult questions to answer.  In fact these are not scientific questions but belong to the province of humanism: the ethics, values, and knowledge surrounding acts of human creation.  A particularly apocalyptic example is that of nuclear physics: a branch of science that has given us the atomic bomb.  While science for its part has created the technology and power, it is us, as humans, that must determine its use.

Asking conditional statements about the future invokes creativity and imagination.  However, before we imagine and create something,  we must determine what values will be our guide.  What we create is a reflection of us and this is carried out through the values that we hold.   We often take for granted the legacy of values that have been passed down to us.  Many of us accept these values as right, just and valid in as much our teachers accepted them as well.  For example, common medical values include: 

  • Respect for autonomy
  • Beneficence
  • Non-maleficence
  • Justice

One such value that is tacitly implied in the four values above is that a provider treats a patient to alleviate, cure or palliate.  We have seen this value reflected in our own practice in the innumerable treatments that have come, gone and stuck-around: ultrasound, infrared, manipulation, iontophoresis, phonophoresis…etc.  Suffice to say we have applied every (safe) aspect of the electromagnetic spectrum to the body with the hopes of changing  the patient’s subjective experience (i.e. the patient’s pain).  I would summarize this value is the patient is to be treated value.  Inherent to this value is that we must do something to the patient, what that something is I will get to later.

Many of these treatments listed above have been applied–for years if not thousands of years–in advance of any scientific evidence.  As the science has caught up, the evidence has not shown to match with the anecdotal experiences of clinicians and patients (see some systematic reviews listed below).   A therapist might say, “I performed X technique and the patient got better.” Post hoc ergo propter hoc is the fallacy that I did X, and because Y changed it is therefore because of X.  This fallacy has created a paradox between the clinician’s experience and what science tells us is occurring.  Fortunately, science is catching up and describing the clinical encounter with greater fidelity.  Much of this research is being carried out in labs that emphasize psychology, neuroscience, social-contextual effects and placebo.  For some excellent reviews see the links section below.

Based on this new research, the something (i.e. treatment techniques) that I mentioned above, that are the cornerstones of our practice are turning out to be different than we originally conceptualized.  Leaders in our field are aware of some of this evidence.  Unfortunately, for many this new science only helps justify things we have already been doing for years. From this perspective the application of new science adds little value to our profession.  If we instead flip our perspective by including humanistic questions like: “In light of this new evidence, what should we be doing as a profession?” and “What could we be doing instead of what we have been?”  we, I believe, can facilitate a discussion that provides immense value to our profession and our patients.

I look forward to getting deeper into this discussion with your input.  Future posts will expand upon the following:

  • Post hoc ergo propter hoc — Otherwise known as the misattribution bias in the physical therapy treatment of pain.
  • How can we use emerging research to re-conceptualize our practice?
  • Should we be taking responsibility for changes in the patient’s pain?

Discussion of these topics and more will involve the evidence i.e. science, but it will also critically examine the values we attach to the things that we do.  My hope is that if have a nuanced discussion not only about the evidence but also including our values we will be able to move forward.

Eric Kruger @Kintegrate

P.S. An interesting and somewhat related tangent, for an example of a  prescient view of the future read, Isaac Asimov’s Visit to the World’s Fair of 2014 from the New York Times in 1964.

Articles highlighting social/contextual factors and placebo:

Benedetti, F. (2013). Placebo and the new physiology of the doctor-patient relationship. Physiological reviews93(3), 1207-1246.

Bialosky, J. E., Bishop, M. D., Price, D. D., Robinson, M. E., & George, S. Z. (2009). The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Manual therapy14(5), 531-538.

Craig, K. D. (2009). The social communication model of pain. Canadian Psychology/Psychologie canadienne50(1), 22.

Krahé, C., Springer, A., Weinman, J. A., & Fotopoulou, A. (2013). The social modulation of pain: others as predictive signals of salience–a systematic review.Frontiers in human neuroscience7.

Some links to systemic reviews of the evidence:

de las Peñas, C. F., Sohrbeck Campo, M., Fernández Carnero, J., & Miangolarra Page, J. C. (2005). Manual therapies in myofascial trigger point treatment: a systematic review. Journal of bodywork and movement therapies,9(1), 27-34.

Miller, J., Gross, A., D’Sylva, J., Burnie, S. J., Goldsmith, C. H., Graham, N., … & Hoving, J. L. (2010). Manual therapy and exercise for neck pain: a systematic review. Manual therapy15(4), 334-354.

White, A. R., & Ernst, E. (1999). A systematic review of randomized controlled trials of acupuncture for neck pain. Rheumatology38(2), 143-147.

van der Windt, D. A., van der Heijden, G. J., van den Berg, S. G., ter Riet, G., de Winter, A. F., & Bouter, L. M. (1999). Ultrasound therapy for musculoskeletal disorders: a systematic review. Pain81(3), 257-271.

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5 replies »

  1. Welcome aboard Eric and nice first post. I am not sure that what you are describing is a “drawback” of science. It is more a limitation of the tool. Science is a process which helps us determine truth. When we enter the realm of preferences which have no one right or wrong answer science is no longer a useful tool. However, some have argued that the scientific process can be used to answer questions about morals and values. I am interested what you think of this TedTalk by Sam Harris? http://www.ted.com/talks/sam_harris_science_can_show_what_s_right.html

  2. @Eric
    Nice post and I get the point you are making. The essence of what we are doing is not in the existence of science (no matter if it is epidemiological or fundamental science), but in the intentions of us as professionals. However it’s not just us as professionals who are defining our profession. Humanism also means taking the values of the patients in sincere consideration. As much as we define both the condition of the patient, the patient enacts his or her own condition too (1). And if this principle is applicable for the condition of the patient (or client, if you like), it might just be applicable for interventions too.
    I like the way you take ethics, especially applied medical ethics in consideration. I tend to think that epidemiological, nor fundamental research can replace ethical theories like social contract theory / the theory of justice (Rawls) (3) and the ethics of care (Tronto)(4). If we take the dynamics of both patient specific and therapist specific values into consideration, we might need ethics that rather focus on how to establish and define interpersonal relations, rather then focussing on intrensic or instrumental values. This will probably fit the dynamic reality of our profession better.

    @Adam Rufa
    The reading of Sam Harris is merely a sales talk on his book “the moral landscape, how science can determine moral values”. This book was widely critisized and discussed by his forestanders (Michael Shermer, Richard Carrier) as well as opponents (Massimo Pigliucci, Ophelia Benson), and discussion was awnsered by Harris (5-8). I don’t want it to be left unnoted that neither of these are moral relativists, nor absolutists.
    Aside from known cricics, Sam Harris places science at the base of ethics. Science is not, as you say getting to know the truth, alone. Getting to know the truth is from a philosophical point of view, a logical positivism standpoint. Later Karl Popper stated that science demarcated itself by a binairy principle of falsification. In other words science might just be about getting to know what isn’t true. Popper in turn was critisized by Kuhn about the observation that the essence of science was determined not by objective an methodological coherent third person behavior, but that the behavior was defined within the scientific paradigma. Ymre Lakatos joined the discussion by pointing out the shortcomings of a binary demarcation criterium like falsification. (no links added, see Wikipedia). If all would agree however to one principle about science, I guess it would be that science tries to look at causal relations and prediction of consequences.
    Above leads me to think that someone who states that science can determine human values, firstly states that in establishing values are consequences, thus only accepts logical arguments based on utilitarianism (9-10). Leaving deontological and other consequentialistic arguments like teleological ethical arguments (9-11) out of the picture however leads to less dynamics, that I think fits our daily practice. Although I might not win Hariss’s challenge (12), I think I can make a point of critique on Harrises view on moral values. Not just is he falsely excluding well described ethical theories, however this makes the outcome in reasoning less heterogenic, it’s also a non sequitur, that even if moral values are material consequences, the norm still isn’t. The norm might be fit to the relation (tronto), the social agreements (Rawls), principles (Kant), or personal charcacter (Aristotele), just to name some.

    1. doc.utwente.nl/48819/1/Hypo39.pdf
    2. dare.uva.nl/document/212420
    3a. http://en.wikipedia.org/wiki/Social_contract
    3b. http://en.wikipedia.org/wiki/Theory_of_justice
    4. http://en.wikipedia.org/wiki/Ethics_of_care
    5. http://www.samharris.org/site/full_text/response-to-critics
    6. http://rationallyspeakingpodcast.org/show/rs85-live-from-necss-with-michael-shermer-on-the-role-of-sci.html
    7. http://rationallyspeaking.blogspot.be/2013/10/objective-moral-truth-thoughts-on.html
    8. http://rationallyspeaking.blogspot.be/2013/04/science-morality-and-genital-mutilation.html
    9. http://en.wikipedia.org/wiki/Utilitarianism
    10.http://en.wikipedia.org/wiki/Consequentialism
    11. http://en.wikipedia.org/wiki/Deontological_ethics
    12. http://www.samharris.org/blog/item/the-moral-landscape-challenge1

  3. Adam, Thanks for the reply. I agree with you perhaps I did not phrase that part quite right. Although, I do not subscribe to the view that science tells us truths, it can only really tell us what is less wrong–never what is essentially and absolutely right or wrong. Perhaps a trivial point for some but not for me. The video is interesting and hypocritical. Some values can be reduced to facts, others can’t. Some questions can be answered and others can’t. These premises then lead to the conclusion all humanistic (morality) questions can be solved by science. This seems like an error in logic par excellence. He then states health is not vacuous, but then precedes to define it in a negative state as “not death”. What? The defines truths about human nutrition as identifying poison or not poison. Again what? There are so many logical errors and fallacies in his talk it is absurd, false dilemmas, arguments out of consequences, arguments out of fear, cherry picking (i.e. low hanging fruit) all the Islamic references to a white and American audience (come on).

    I don’t agree with his tactics or his conclusions (about science weighing in on morality). Regardless I feel about his actual values it is poor form. This review pretty much sums up everything I think. http://blog.practicalethics.ox.ac.uk/2011/11/sam-harris-is-wrong-about-science-and-morality/

    In my post I advocated for a merger of the two, perhaps it is better to think of humanistic thinking i.e. moral reasoning as a suite of thinking tools dealing with values, ethics and morality. What I am not advocating for is a hegemony of science or scientists dictating what is good, right, and wrong. What I think needs better development in people that are scientists and people that use science is humanistic thinking. In tandem with this to be absolutely clear when they are using their science hats, when they are using their humanistic hats and how they are citing the evidence in relation to either.

    What the video advocates implicitly and explicitly at times is the scientists have the tools to do just that. However, Sam Harris is rhetorician and self aggrandizing one at that, on par with Malcolm Gladwell. Fundamentally, scientists do science a disservice when they try to argue answers to humanistic questions with science or from an appeal of a scientific authority as Sam Harris does. They should openly admit their humanistic values and argue those values on such terms. If they want to cite evidence it must be operationally defined as it could relate to such and such value so it can be openly argued for or against.

    This is exactly why I started my first post by drawing a clear line in the sand if you will between the two. I want to to talk about complex practice issues but I don’t want to fight values with science or science with values. IMO, this occurs over and over again in professional discussions online. If not done well, and openly there is potential for much confusion and animosity when broaching such subjects.

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