I’m really not one to get drawn into SoMe arguments etc, (no, seriously) but there is something really enticing about a recent discussion on Twitter to which I am inclined to cast some further thoughts. Note that this is not any sort of attack on individuals (of whom I hold utmost respect). Maybe it’s more about the complexities of SoMe, the desire and passion to promote what are thought to be the most important health care messages, and such forth. Maybe.
IT BEGAN WITH a nice, brief editorial published by leading musculoskeletal researchers calling, quite rightly, for better evidence-informed marketing within physiotherapy, specifically regarding low back pain: “Associations should ground their marketing on rock solid research data”. So far, so good. The authors made a suggestion that some physiotherapy interventions were harmful, to quote:
“Early access to harmful or ineffective physical therapy treatments (eg, kinesiotape and electrotherapy), irrespective of timing, is unlikely to improve patient outcomes7” (ibid)
Still so far so good. Citation “7” is a (excellent) summary of thought and position on the gap between evidence and practice. However, other than brief comments about risks associated with NSAIDs, opioids, epidural, and spinal fusion, there are no data nor reference to any data about harm of physical therapy interventions in the cited paper.
SO THEN A COUPLE OF COLLEAGUES AND I wrote a brief response asking for clarity on the “harm data” issue. We, of course, agreed entirely with the comments about lack of effectiveness, closing the gap between evidence and practice, etc, but it was the harm statement we were interested in. Basically, we asked if the authors could provide data for claiming that some physical therapy interventions were harmful, or sensibly withdraw that statement. We felt this was important in order to get the best scientific appreciation of the state of physical therapy as possible, and were concerned about how therapists, patients, stakeholders, etc, might interpret this.
THEN TWITTER HAPPENED. This is a summary of the responses to the question “could you please provide data on harm for physical therapy interventions, eg, kinesiotape and electrotherapy”. This is about logic and dialogue, not about individuals, so I am not stating names here. Tweets are in “quotes italics”, followed by *my comments in asterisks*:
“If people are demanding that ‘harm’ be defined; why are they practising? I would have thought this concept is a core element of any health training program”
*A circumstantial ad hominem response. A passive-aggressive comment about a person’s situation with the aim of undermining the person asking the original question*
“There has been a recent demand on Twitter to define “harm” in relation to physio interventions. I want to know how to define “benefit” and if research is scrutinised to the same extent when claiming a treatment is beneficial without justification beyond statistical significance”
“Do you mean adverse event rates in PT trials? I attach data for PROMISE (Lancet 2014; 384: 133–4)” (NOTE: these data related to 5/157 adverse events from exercise and advice groups in a neck pain trial, not harm caused by “physical therapy interventions, eg, kinesiotape and electrotherapy” in people with low back pain)
*Distraction fallacies. Intending to distract the person from the original point. The main argument may thus never be completed to a logical conclusion*
“Sorry, but I am lost on what you want. I provided harms data as per the report you referred me to”*Argumentum ad nauseam. Keep avoiding the core question until all parties lose interest*
“Hardly a causal claim. Looks like you’ve misinterpreted what we wrote”
“…but IMHO that was not a causal statement as some have been trying to say”
“No, definitely not, it does NOT say physiotherapy is harmful, agree. It (sort of) says that some physiotherapy interventions may be harmful”
“Those words weren’t in the editorial; they are yours. I thought the editorial was referring to ineffective treatments that have potential for adverse effects”
*Informally denying the antecedent. If the premise is not true, then neither is the conclusion. What bit of “harmful or ineffective physical therapy treatments” is not casual?*
“Clutching at straws Roger. Save your time”
*Avoid the issue, close down the argument and we can never be proved wrong*
*Argumentum ex silentio. Say nothing and parties will assume there is nothing to argue against*
BUT FINALLY! An admission that THERE ARE NO DATA ON HARM for the sorts of interventions referred to:
“There is body of literature on this complex issue. e.g. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4284159/ … Many trials will be biased toward the null. No evidence of harm ≠ safe”
*and on this logic then no evidence of harm ≠ harmful*
If harm=stat sig more AEs with PT; then I cannot recall an example as most PT RCTs are under-powered to detect AEs. But the imprecision means you cannot call them safe either. Double-edged sword.
Phew! We got there! But this experience begs a couple of question:
- Why did a group of leading international scientific researchers and their supporters employ so many logical fallacies and avoidance strategies in response to a clear, simple, black-and-white question about data?
- Why did a group of leading international scientific researchers make a causal statement in a professional, scientific, peer-reviewed publication about cause and effect that they knew not to be true?
‘But this sentence about harm was such a tiny part of what was written in the original article’ you cry.
Indeed it was my friends. But like a tiny crack in the door, this is how the light gets in. Is this small, seemingly “clutching at straws” statement a light-signal of truth about scientists fabricating statements in order to support a particular agenda perhaps?
If so, if such people are consciously willing to fabricate a causal statement like this, what else are they willing to fabricate? This is an issue of scientific and professional integrity, creditworthiness, and trustworthiness. These issues are especially exaggerated as the false statement was part of an explicit call for better use of scientific evidence and “rock solid data” in professional dialogue.
Finally, I’m going to fabricate a new fallacy of my own: argumentum ad ironicus©
“I enjoy tough questions on twitter. But there needs to be respect & integrity; & debate needs to be grounded in science. If those are missing I opt out”
For your listening pleasure: Leonard Cohen, Anthem
Image credit: cracked door, Alec Squire, Flikr 2013
UPDATE, Jan 2019: