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What are these “turf wars” founded on?

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Some months ago, I wrote a post in Norwegian (Datatrøbbel) where I tried to calm my nerves on why there seems to be so much disagreement between the health care practitioners treating symptoms from the neuromusculoskeletal system. It really helped, to get it “out there”, off my mind and away, but off course, the ongoing discussion still lives on and probably will – loooong time after it’s my time to leave the building…

Anyway, I came over this tweet from @PainPhysiosCan where @PranaPT blogs about Turf Wars Among Health Care Practitioners. I highly recommend anyone planning to read my post, to read her post first, just to probe you all into the right context.

As this is not really a direct reply to her encouragement being “let’s all start playing nice in the sandbox” I’ll post a short translated summary of the previous post that at least for me, eased my mind on this topic. In one sentence, the whole post was about 5 possible reasons of WHY we still see these turf wars @PranaPT puts her spotlights on.

Translated, the post was called Data Trouble in the Musculoskeletal World. Moving on…

When trying to solve any kind of problem,

we must first try to get an overview of attainable information (data) to make some kind of fundament for a potential solution to the problem. Most health-care practitioners make their potential solution based on data concerning the patients own information and thoughts about his/hers own problem, the practitioners own theoretical and educational database and data that concerns symptom response and behavior to movement.

The first challenge arises even when trying to define what a data actually is. Importantly, a data in itself is just one tiny piece of information/parameter retracted out from a larger material. It is the lowest level of any information and in itself, does not have any meaning. It must be put together with another data to have any value at all – it must be relative to something else. If a person gives us data like “I have pain” we need more data about where he/she has pain to even start our diagnostic process. A patient giving you data on “I have pain”, but unable to give you data about where and when, will probably manifest quite a challenge to help.

Secondly, one piece of data, in one context, will have a totally different value and meaning in another context. For example, if we’d ask a marathon participant after they crossed the finish-line; How do you feel now? and they replied “I’m in pain” we would probably value the word pain quite differently than if it came from a person sitting in a treatment room. Another example: in depth knowledge on Ph.D level about Substance P and other neuropeptides will be very impressive when talking about pain with e.g. a “regular” physio, but this knowledge will almost be totally meaningless when talking about pain with a “regular” patient.

Context of any kind of data attained is therefor highly important. The processing of the data forms the conclusion (where confirmation bias is the trickiest little devil), and as we all know, the diagnostic “accuracy” of a musculoskeletal movement/symptom response evaluation is not very reliable. Or even valid. And lets not even get into the role of qualitative vs. quantitative data in here. Nevertheless – the turf war is on. So, why?

1. Everyone disagrees on which data should be the most important, and everyone disagrees on what the data really means.

2. Exclusive feeling of copyright over the data, between the “manual body workers”. This is due to a historical time when the different therapies was formed, a time where it was important to identify a data to claim as their “own”. The motivation for this was to have a unique “turf” to build their identity and body of profession on. The chiro’s “claimed” the spinal joint, the physio’s claimed the muscle, and the osteo’s claimed the fascia. Then there are cultural differences between the continents. The cultural, historical and philosophical background of every profession will therefore undoubtedly influence which data we think is important to identify, to collect, assess, evaluate in a neuromusculoskeletal “professional” assessment. And off course, we will all fight to the bitter end to defend our own “turfs” because there are more culture, philosophy and history laid down in those landscapes then what we might realize.

"You can put lipstick on a pig, but it's still a pig."

3. There is too much data to keep track of! Most behavioral analysts agree that we express much more data with our body language than with our words. PubMed holds 20 million references, increasing with 3-4000 references a day! And that is without thinking about all the books and unpublished articles around, between the “manual body workers” alone. It is absolutely impossible to learn every data that concerns neuromusculoskeletal function. The consequences are that we find the most similar data of interest numerous times, over and over again, calling them different names, putting different labels on the same data, messing up the nomenclature even more. And usually, the more fancier the name, the more plausible it claims to be. Paul Ingraham wrote entertainingly //for some, provocative for others// about what this need for exclusive labeling can end up as in his post Therapy Babble. Basically, the labeling of these “data” are just small variations around the same theme… And who decides which of all these data are the most important? Maybe more important, who decides which data are pure noise (red herrings)?

4. Conflict of interest between the practitioner and the patient. It is easy to forget, that the patient is the owner of most of the data we are all so interested in. To lure these data cleverly out, we need to communicate extremely well with the patient. And shall we not even get into the issue of varying communication skills… The real “challenge” is that the patient is probably eager to tell us about a whole different set of data then we are (and nobody can claim them for wanting so).

5. Excellent clinical reasoning seriously challenges inborn, inherited intuition. Pain, the most prevalent symptom associated with decreased neuromusculoskeletal function, is non-linear, and not anything like a biomechanical calculation. As such, in an abstract world where there are no clear cut off values and well defined boundaries between “pain” and “no pain”, “sick” or “healthy”, we enter a landscape full of traitorous traps just waiting for us to commit cognitive fallacies leading an otherwise logical train of thought way off track. Some of these traps will be named post hoc, ergo propter hoc and circular reasoning, where the conclusion based on the data collection one innocently thought were correct, really is not, and never probably will.

One clever take to this “total anarchy” of data sets “gone wild” was brought to me by Michael Shermer, founding publisher of Skpetic Magazine (ey, nothing wrong with that??) who said:




To choose a path of treatment based on what-if-when-if data will probably lead you down an equally wishful theory. The fact that patients still will report positive clinical outcomes based on treatment-interventions built on invalid data sets and context, is a whole different matter.

I’d love to hear some feedback on this as I probably missed out several possible reasons as of why health care practitioners still continues to ramble on these war turfs. And, will we ever play nicely along in the sandbox? At which cost?

Postet av Sigurd   @   13 March 2012 2 kommentarer

2 kommentarer

Mar 14, 2012
#1 Ann Wendel :

Thank you for sharing your thoughts on the topic. I agree that we are always looking for a balance between data and theory.
Best regards,

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