iPhone Targeted Content
iPad Targeted Content
Android Targeted Content
Blackberry Targeted Content
Desktop and all none targeted content
iPhone Targeted Content
Uncertainty Sets You Free
April 17, 2016 by Dr Matthew D. Long
SHARE 
iPad Targeted Content
Android Targeted Content
Uncertainty Sets You Free
April 17, 2016 by Dr Matthew D. Long
SHARE
Blackberry Targeted Content
Desktop and all none targeted content
Uncertainty Sets You Free
April 17, 2016 by Dr Matthew D. Long
SHARE
They say that there are only two certainties in life - death and taxes. The rest is all a bit vague. It might seem paradoxical that a blog called "Clinical Clarity" is so hung up on uncertainty. Indeed, I have written previously at length about the inherent 'fuzziness' of clinical practice and how this can undermine our clinical decisions. But that's the point - we need to be clear about the reality of our world, so that we can operate effectively within it. And the terrain of our world is uncertain.
One of the hallmarks of maturity is an awareness that things aren't black and white. But it takes self-awareness and insight to know this, and humans aren't always good at self-reflection - even trained health professionals. The sheer complexity of dealing with biological systems is daunting and the lack of diagnostic clarity can be overwhelming for many clinicians. As such, there is often a tendency to retreat into approaches or techniques that seem to offer a clear way forward. While it is admirable that we have tried to find some clarity amongst the chaos, it is often done without much in the way of scientific accountability. Indeed, many of the assumptions and models used do not stand up to scrutiny - yet this does not seem to prevent ongoing enthusiasm for their use.
But why is this so? Are we fooling ourselves?
It is clear that human beings are hard-wired to see patterns when often none exist. In a complex and “noisy” world, rapid pattern-recognition aids our survival, particularly if it helps us avoid threats or gain benefits on a consistent basis. The trouble is, our brains are easily fooled, and this is apparent throughout all human endeavours. As author Scott Adams wrote (1),
One of the hallmarks of maturity is an awareness that things aren't black and white. But it takes self-awareness and insight to know this, and humans aren't always good at self-reflection - even trained health professionals. The sheer complexity of dealing with biological systems is daunting and the lack of diagnostic clarity can be overwhelming for many clinicians. As such, there is often a tendency to retreat into approaches or techniques that seem to offer a clear way forward. While it is admirable that we have tried to find some clarity amongst the chaos, it is often done without much in the way of scientific accountability. Indeed, many of the assumptions and models used do not stand up to scrutiny - yet this does not seem to prevent ongoing enthusiasm for their use.
But why is this so? Are we fooling ourselves?
It is clear that human beings are hard-wired to see patterns when often none exist. In a complex and “noisy” world, rapid pattern-recognition aids our survival, particularly if it helps us avoid threats or gain benefits on a consistent basis. The trouble is, our brains are easily fooled, and this is apparent throughout all human endeavours. As author Scott Adams wrote (1),
"People are not wired to be rational. Our brains simply evolved to keep us alive. Brains did not evolve to give us truth. Brains merely give us movies in our minds that keeps us sane and motivated. But none of it is rational or true, except maybe sometimes by coincidence."
Unfortunately, clinical practice is no exception. Chad Cook wrote an excellent piece on the challenges of clinical decision making in The Journal of Manual & Manipulative Therapy (2).
"Practicing clinicians rely on their clinical reasoning skills in order to make pertinent and appropriate care decisions when faced with a large amount of data and uncertainty... Most commonly, this process is altered by experience, exposure, and internal biases and is propelled by clinical gestalt."
He further went on to examine the problems inherent in our typical approach to the patient examination:
"Although intuitive, gestalt-based decision-making is riddled with five tangible errors:
(1) the representative heuristic (if it’s similar to something else, it must be like that);
(2) the availability heuristic (we are more inclined to find something if it’s something we are used to finding);
(3) the confirmatory bias (looking for things in the exam to substantiate what we want to find);
(4) the illusory correlation (linking events when there is actually no relationship); and
(5) overconfidence.
(2) the availability heuristic (we are more inclined to find something if it’s something we are used to finding);
(3) the confirmatory bias (looking for things in the exam to substantiate what we want to find);
(4) the illusory correlation (linking events when there is actually no relationship); and
(5) overconfidence.
Of these 5 decision-making errors, overconfidence may be the most compelling. Most diagnosticians feel that they are better decision-makers than what they demonstrate in actual clinical practice. In fact, the least skilled diagnosticians are also the most overconfident and most likely to make a mistake." (3)
Now this might all seem somewhat confronting, but I would contend that we really should be aware of the limitations of our psyche. The truth is, we cannot help but predict what we are about to see (or feel) when examining a patient, it's just the way that we are designed. Interestingly, this is no more apparent than when we consider the act of palpation.
Palpation is a complex sensory undertaking and requires many years of practise to gain confidence in. However, research has time and again shown us that humans are simply not capable of detecting the things we claim to feel beneath our fingers. Whether this is a specific anatomical structure (such as the iliolumbar ligament), or a lost plane of a motion in a vertebral segment, the subtle flow of CSF, or even the tiny motion characteristics of a sacroiliac joint, science has determined that we simply cannot perceive these with any certainty (4-17). However, this does not seem to have stopped us from utilising these techniques with our patients, and basing important treatment decisions upon them.
Why is this so? How could experienced clinicians get it so wrong (if indeed they are wrong)? Again, this comes back to the human brain and its talent for making predictions. When attempting to make sense of the tissues beneath our fingers, we often fall prey to a phenomenon called pareidolia. This has been defined as,
Palpation is a complex sensory undertaking and requires many years of practise to gain confidence in. However, research has time and again shown us that humans are simply not capable of detecting the things we claim to feel beneath our fingers. Whether this is a specific anatomical structure (such as the iliolumbar ligament), or a lost plane of a motion in a vertebral segment, the subtle flow of CSF, or even the tiny motion characteristics of a sacroiliac joint, science has determined that we simply cannot perceive these with any certainty (4-17). However, this does not seem to have stopped us from utilising these techniques with our patients, and basing important treatment decisions upon them.
Why is this so? How could experienced clinicians get it so wrong (if indeed they are wrong)? Again, this comes back to the human brain and its talent for making predictions. When attempting to make sense of the tissues beneath our fingers, we often fall prey to a phenomenon called pareidolia. This has been defined as,
'A psychological phenomenon involving a stimulus wherein the mind perceives a familiar pattern of something where none actually exists'
According to Wikipedia, common examples are “perceived images of animals, faces or objects in cloud formations, hidden messages within recorded music played in reverse”. But pareidolia is not limited only to visual or auditory stimuli - our palpatory abilities also fall victim to this. Indeed, you can read an excellent article by Paul Ingraham (18) about “palpatory pareidolia” here. It is easy to convince ourselves that we can detect subtle variations in anatomical structure or movement, where in reality, these account for little more than a random noise. This does not mean that all aspects of a physical examination are useless, but it is most important that we understand what we can rely upon, and what is simply wishful thinking.
I would argue that an important part of clinical maturity is acknowledging the limitations that we all have when practising our art. By acknowledging inconsistencies and understanding where gaps in our knowledge lie, we can focus our attentions on building a robust body of knowledge that we can rely upon.
I understand that such claims of fallibility and uncertainty may sound far-fetched and perhaps even insulting to those with many years of clinical practice. But even a cursory evaluation of the research literature might reassure you that we can’t always trust our senses, or our experience.
As a light-hearted aside, you might be familiar with the various internet debates that have arisen in recent times about the supposed colour of items of clothing posted on websites. A couple of recent examples (shown below), illustrates this nicely. Take a look at the Adidas jacket on the left (posted by US high school girl Nina Penzo on Tumblr). What colours do you see in the jacket? According to Adidas, the jacket is “baby blue and white”. However, only about 18% of people actually see the jacket as this colour in the photo shown. Personally, I see a green and gold jacket, whilst many others see black and brown, or green and brown, or pink and grey.
I would argue that an important part of clinical maturity is acknowledging the limitations that we all have when practising our art. By acknowledging inconsistencies and understanding where gaps in our knowledge lie, we can focus our attentions on building a robust body of knowledge that we can rely upon.
I understand that such claims of fallibility and uncertainty may sound far-fetched and perhaps even insulting to those with many years of clinical practice. But even a cursory evaluation of the research literature might reassure you that we can’t always trust our senses, or our experience.
As a light-hearted aside, you might be familiar with the various internet debates that have arisen in recent times about the supposed colour of items of clothing posted on websites. A couple of recent examples (shown below), illustrates this nicely. Take a look at the Adidas jacket on the left (posted by US high school girl Nina Penzo on Tumblr). What colours do you see in the jacket? According to Adidas, the jacket is “baby blue and white”. However, only about 18% of people actually see the jacket as this colour in the photo shown. Personally, I see a green and gold jacket, whilst many others see black and brown, or green and brown, or pink and grey.
How about the image of the dress on the right above, also posted on Tumblr? What colours do you see? I see a gold and white striped dress, but many see the same image as blue and black. There have been many vocal arguments about these two images, and incredulous stares as family members simply cannot believe that someone they know and respect would see the world so “wrongly”. Human sensation is a fickle thing and it will serve us well to acknowledge that.
So what's the point?
All clinicians have to make decisions about their patients. To do this well, we need a model that explains what has gone wrong inside the patient, and a reliable way of examining them. But it is becoming increasingly apparent that our traditional understanding of spinal disorders is woefully insufficient. Evidence now suggests that the neurological dysfunction chiropractors have sought within the spine, most likely resides within the brain itself. Furthermore, our reliance upon local palpation to assess spinal dysfunction (misalignment or stiffness) seems less important when we adopt a brain-based model. Of course, I am not suggesting that the brain is the sole cause of spinal derangement, or that there is no value in making a tissue-diagnosis - far from it. However, I would contend that a clinical approach that depends almost exclusively upon palpation of the spine should be re-evaluated.
I hope this blog post has got you thinking, and questioning some of the notions that you may rely upon every day in practice. On first reading, you might find this article discouraging, but I find it liberating to know where our weaknesses lie. Furthermore, if you investigate the literature and appreciate the clarity that it brings, you will find new avenues to gain the clinical certainty that we all crave.
Something to think about...
Dr Matthew D. Long
BSc (Syd) M.Chiro (Macq)
So what's the point?
All clinicians have to make decisions about their patients. To do this well, we need a model that explains what has gone wrong inside the patient, and a reliable way of examining them. But it is becoming increasingly apparent that our traditional understanding of spinal disorders is woefully insufficient. Evidence now suggests that the neurological dysfunction chiropractors have sought within the spine, most likely resides within the brain itself. Furthermore, our reliance upon local palpation to assess spinal dysfunction (misalignment or stiffness) seems less important when we adopt a brain-based model. Of course, I am not suggesting that the brain is the sole cause of spinal derangement, or that there is no value in making a tissue-diagnosis - far from it. However, I would contend that a clinical approach that depends almost exclusively upon palpation of the spine should be re-evaluated.
I hope this blog post has got you thinking, and questioning some of the notions that you may rely upon every day in practice. On first reading, you might find this article discouraging, but I find it liberating to know where our weaknesses lie. Furthermore, if you investigate the literature and appreciate the clarity that it brings, you will find new avenues to gain the clinical certainty that we all crave.
Something to think about...
Dr Matthew D. Long
BSc (Syd) M.Chiro (Macq)
References:
1. Adams, Scott. http://blog.dilbert.com/post/141090636816/donald-trump-con-man
2. Cook, C. (2009). Is Clinical Gestalt Good Enough? The Journal of Manual & Manipulative Therapy, (17), 1–2.
3. Berner ED, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med 2008;121:2–23.
4. Haneline, M. T., & Young, M. (2009). A review of intraexaminer and interexaminer reliability of static spinal palpation: a literature synthesis. Journal of Manipulative and Physiological Therapeutics, 32(5), 379–386. http://doi.org/10.1016/j.jmpt.2009.04.010
5. Haneline, M., Cooperstein, R., Young, M., & Birkeland, K. (2009). An annotated bibliography of spinal motion palpation reliability studies. JCCA Journal of the Canadian Chiropractic Association Journal De l'Association Chiropratique Canadienne, 53(1), 40–58.
6. Stochkendahl, M. J., Christensen, H. W., Hartvigsen, J., Vach, W., Haas, M., Hestbaek, L., et al. (2006). Manual examination of the spine: a systematic critical literature review of reproducibility. Journal of Manipulative and Physiological Therapeutics, 29(6), 475–85, 485.e1–10. http://doi.org/10.1016/j.jmpt.2006.06.011
7. Sabini, R. C., Leo, C. S., & Moore, A. E. (2013). The relation of experience in osteopathic palpation and object identification. Chiropractic & Manual Therapies, 21(1), 38. http://doi.org/10.1186/2045-709X-21-38
8. Merz, O., Wolf, U., Robert, M., Gesing, V., & Rominger, M. (2013). Validity of palpation techniques for the identification of the spinous process L5. Man Ther, 18(4), 333–338. http://doi.org/10.1016/j.math.2012.12.003
9. Kilby, J., Heneghan, N. R., & Maybury, M. (2012). Manual palpation of lumbo-pelvic landmarks: a validity study. Man Ther, 17(3), 259–262. http://doi.org/10.1016/j.math.2011.08.008
10. Robinson, R., Robinson, H. S., Bjørke, G., & Kvale, A. (2009). Reliability and validity of a palpation technique for identifying the spinous processes of C7 and L5. Manual Therapy, 14(4), 409–414. http://doi.org/10.1016/j.math.2008.06.002
11. Holmgren, U., & Waling, K. (2008). Inter-examiner reliability of four static palpation tests used for assessing pelvic dysfunction. Manual Therapy, 13(1), 50–56. http://doi.org/10.1016/j.math.2006.09.009
12. Schneider, M., Erhard, R., Brach, J., Tellin, W., Imbarlina, F., & Delitto, A. (2008). Spinal palpation for lumbar segmental mobility and pain provocation: an interexaminer reliability study. Journal of Manipulative and Physiological Therapeutics, 31(6), 465–473. http://doi.org/10.1016/j.jmpt.2008.06.004
13. Robinson, H. S., Brox, J. I., Robinson, R., Bjelland, E., Solem, S., & Telje, T. (2007). The reliability of selected motion- and pain provocation tests for the sacroiliac joint. Manual Therapy, 12(1), 72–79. http://doi.org/10.1016/j.math.2005.09.004
14. McGrath, M. C. (2006). Palpation of the sacroiliac joint: An anatomical and sensory challenge. International Journal of Osteopathic Medicine, 9, 103–107.
15. Seffinger, M. A., Najm, W. I., Mishra, S. I., Adams, A., Dickerson, V. M., Murphy, L. S., & Reinsch, S. (2004). Reliability of spinal palpation for diagnosis of back and neck pain: a systematic review of the literature. Spine, 29(19), E413–25.
16. Sommerfeld, P., Kaider, A., & Klein, P. (2004). Inter- and intraexaminer reliability in palpation of the "primary respiratory mechanism" within the “cranial concept.” Manual Therapy, 9(1), 22–29.
17. O'Haire, C., & Gibbons, P. (2000). Inter-examiner and intra-examiner agreement for assessing sacroiliac anatomical landmarks using palpation and observation: pilot study. Manual Therapy, 5(1), 13–20. http://doi.org/10.1054/math.1999.0203
18. Ingraham, Paul. https://www.painscience.com/articles/palpatory-pareidolia.php
1. Adams, Scott. http://blog.dilbert.com/post/141090636816/donald-trump-con-man
2. Cook, C. (2009). Is Clinical Gestalt Good Enough? The Journal of Manual & Manipulative Therapy, (17), 1–2.
3. Berner ED, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med 2008;121:2–23.
4. Haneline, M. T., & Young, M. (2009). A review of intraexaminer and interexaminer reliability of static spinal palpation: a literature synthesis. Journal of Manipulative and Physiological Therapeutics, 32(5), 379–386. http://doi.org/10.1016/j.jmpt.2009.04.010
5. Haneline, M., Cooperstein, R., Young, M., & Birkeland, K. (2009). An annotated bibliography of spinal motion palpation reliability studies. JCCA Journal of the Canadian Chiropractic Association Journal De l'Association Chiropratique Canadienne, 53(1), 40–58.
6. Stochkendahl, M. J., Christensen, H. W., Hartvigsen, J., Vach, W., Haas, M., Hestbaek, L., et al. (2006). Manual examination of the spine: a systematic critical literature review of reproducibility. Journal of Manipulative and Physiological Therapeutics, 29(6), 475–85, 485.e1–10. http://doi.org/10.1016/j.jmpt.2006.06.011
7. Sabini, R. C., Leo, C. S., & Moore, A. E. (2013). The relation of experience in osteopathic palpation and object identification. Chiropractic & Manual Therapies, 21(1), 38. http://doi.org/10.1186/2045-709X-21-38
8. Merz, O., Wolf, U., Robert, M., Gesing, V., & Rominger, M. (2013). Validity of palpation techniques for the identification of the spinous process L5. Man Ther, 18(4), 333–338. http://doi.org/10.1016/j.math.2012.12.003
9. Kilby, J., Heneghan, N. R., & Maybury, M. (2012). Manual palpation of lumbo-pelvic landmarks: a validity study. Man Ther, 17(3), 259–262. http://doi.org/10.1016/j.math.2011.08.008
10. Robinson, R., Robinson, H. S., Bjørke, G., & Kvale, A. (2009). Reliability and validity of a palpation technique for identifying the spinous processes of C7 and L5. Manual Therapy, 14(4), 409–414. http://doi.org/10.1016/j.math.2008.06.002
11. Holmgren, U., & Waling, K. (2008). Inter-examiner reliability of four static palpation tests used for assessing pelvic dysfunction. Manual Therapy, 13(1), 50–56. http://doi.org/10.1016/j.math.2006.09.009
12. Schneider, M., Erhard, R., Brach, J., Tellin, W., Imbarlina, F., & Delitto, A. (2008). Spinal palpation for lumbar segmental mobility and pain provocation: an interexaminer reliability study. Journal of Manipulative and Physiological Therapeutics, 31(6), 465–473. http://doi.org/10.1016/j.jmpt.2008.06.004
13. Robinson, H. S., Brox, J. I., Robinson, R., Bjelland, E., Solem, S., & Telje, T. (2007). The reliability of selected motion- and pain provocation tests for the sacroiliac joint. Manual Therapy, 12(1), 72–79. http://doi.org/10.1016/j.math.2005.09.004
14. McGrath, M. C. (2006). Palpation of the sacroiliac joint: An anatomical and sensory challenge. International Journal of Osteopathic Medicine, 9, 103–107.
15. Seffinger, M. A., Najm, W. I., Mishra, S. I., Adams, A., Dickerson, V. M., Murphy, L. S., & Reinsch, S. (2004). Reliability of spinal palpation for diagnosis of back and neck pain: a systematic review of the literature. Spine, 29(19), E413–25.
16. Sommerfeld, P., Kaider, A., & Klein, P. (2004). Inter- and intraexaminer reliability in palpation of the "primary respiratory mechanism" within the “cranial concept.” Manual Therapy, 9(1), 22–29.
17. O'Haire, C., & Gibbons, P. (2000). Inter-examiner and intra-examiner agreement for assessing sacroiliac anatomical landmarks using palpation and observation: pilot study. Manual Therapy, 5(1), 13–20. http://doi.org/10.1054/math.1999.0203
18. Ingraham, Paul. https://www.painscience.com/articles/palpatory-pareidolia.php