Issue link: https://www.massageandbodyworkdigital.com/i/1451559
L i s te n to T h e A B M P Po d c a s t a t a b m p.co m /p o d c a s t s o r w h e reve r yo u a cce s s yo u r favo r i te p o d c a s t s 73 Key terms here are conscientious, explicit, judicious, and individual, which can often be overlooked when using social media shorthand. Conscientious means the practitioner needs to be honest with themselves regarding how much evidence they have, how well they have interpreted it, and whether it applies to the patient in front of them. Explicit means they have openly followed (and if necessary, explained this to the patient) a specific evidence-based path—not vaguely so or based on recall, but literally by scanning the literature and deciding on the most appropriate evidence for the case before them. Judicious means they have exercised critical judgment as to the quality of the evidence and its appropriateness for their patient. All too often, those who enthusiastically embrace evidence-based practice will stress the need to "follow the science" and only ever practice according to the evidence. In a study clearly laying out some of these issues, 2 this approach is called "evidence nihilism." Evidence nihilism is expressed in terms such as: "There is no high-quality evidence investigating the efficacy of Treatment A, so we shouldn't use it"; or: "The evidence does not demonstrate the effectiveness of Treatment A." There are several errors in this way of thinking. Firstly, a lack of evidence does not mean a treatment does not work. It means it has not been sufficiently researched, so our knowledge about it remains limited. That is not the same as using the excuse "the science hasn't caught up" to talk about truly outlandish claims; it is a reasonable statement and should be seen as such. Secondly, if there has been some research, but it does not show positive results, before dismissing the technique one needs to critically appraise the quality of the research. Is it sufficiently robust to definitively demonstrate that a given technique is in fact ineffective? What are the conditions and limitations of the study design? The fine detail of what to look for when appraising such a study is accessibly explained in Trisha Greenhalgh's invaluable handbook for clinicians, 3 and such an evaluation is critical before dismissing a well-established technique, or one with hefty—if hard to read—science behind it. WHAT WORKS AND HOW Sharp-eyed readers may also have noticed that in the example statements of "evidence nihilism" above, I have used "efficacy" in the first, but "effectiveness" in the second. These two words do not mean the same thing. Effectiveness means the way something works in real life, whereas efficacy refers to what results are found in the context of ideal, controlled circumstances, as in a clinical trial. It is well established that the randomized controlled trial (RCT) is not appropriate for all types of treatments—developed as it was for pharmacological experimentation. As far as efficacy versus effectiveness is concerned, researchers and clinicians have often debated which of these is more useful in the context of clinical application, and one of the most strident critics of integrative medicine suggests that positive effectiveness results can be generated based on their context, rather than their true efficacy. In other words, they may seem to work in the clinic even though they show no efficacy in the lab. One example given is that of homeopathy, for which stringent trials have shown no efficacy but considerable effectiveness, which critics put down to the broader psychosocial effects. 4 A third, long-standing area of disagreement is that of mechanisms of action: how a treatment works and how we explain it. This is significant for two main reasons. The Post-Hoc Fallacy This is an error in thinking that can lead us to attribute a positive result (the patient felt better) to a specific cause (our treatment), when their improvement may have been the result of any number of variables, or simply the natural history of their condition (the natural progression of a disease process if not treated). Patient Perceptions Overpromising or overselling the effectiveness of a treatment for which we have little or no concrete evidence to support the direct cause-effect relationship can be unethical and misleading. Understanding mechanisms of action allows us to be slightly more certain that a given technique does have a beneficial effect. It also allows us to ensure that we do not continue to use techniques with little true effectiveness, and that we do not mislead patients as to their effectiveness. Patients may recover due to a range of factors, including placebo, allowing themselves to be cared for, the effect of gentle touch, the sense that they have found an explanation for their problem, or the sense of empowerment that comes with addressing a problem, regardless of the techniques used.