The stupidity of assuming we are alternative medicine

The stupidity of assuming we are alternative medicine

I was today shocked to read a bunch of idiots have lobbied us to be part of AUYSH (for people who don’t know AUYSH- it is the clubbing of all magical medicine from India and one nonsense from Germany). This is what happens if people who are lobbying and in the politics of associations are uneducated and have a poor understanding of medicine.

There are only 2 types of medicine-1. Modern medicine and 2. traditional medicine. Modern medicine is an evolution of traditional medicine and it should be not called allopathy or English medicine. What do I mean by evolution of traditional medicine? Modern medicine developed as we find more science in our traditional methods of treating. Classical example is treatment of malaria using chloroquine.  It is a common method of treating malaria derived from traditional knowledge and it transformed into modern medicine because it has been put through scientific rigor rather than just believing it to be the treatment because someone in the 2 century or some sidhar wrote it in 10 century.  

Physiotherapy is part of modern medicine. Why? Because we don’t believe in the five element theory of disease as in acupuncture or Ayurveda, or some fantastic pseudo-science –“like cures like” (homeopathy) or vertebral subulxation (magic from north America- chiropractic)  and follow modern physiology. We do trials to confirm and deny our science (read Cochrane summaries).  But you will not read those in traditional medicine, were the founders and the bibles which are written in a different era is still considered as the truth.  Modern medicine is dynamic; it changes with new findings and research.

So, pray who are we. We are should be and are department of physical medicine and rehabilitation.  We are part of a team of health provider including physicians, surgeons (as in acute physical medicine- example, cardiorespiratory PT), with OT, clinical psychologist and others as in case of Neuro-rehabilitation. I hope I don’t have to elaborate on ortho-PT (where I believe we should be primary health care providers in case of cold orthopedics and part of the team in traumatolgy). We should be striving for these issues. We should learn to be primary source of knowledge in these areas and work as part of the medical team. A classical example is dental. T they are part of the modern medicine and at the same time have created a knowledge base of dentistry which is unique to them (remember some of their principles will be similar to ortho).

Sensible people should educate our presidents, prime ministers and other cabinet ministers of our association

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The importance of using the right language while talking science

The importance of using the right language while talking science

One of the biggest concern for me in PT (especially in India) is the advent of newer terminologies in describing- well either imaginary things or already existing things.

1.       The first example is a classic- the trigger point release. When I went to college it was called like in any sensible medical literature as tender spot. Along came the 2000s and with than came in fancy treatment-  TRp release.

The first issue is whether it is the Ashi point as they called in magic (I am referring to acupuncture) or trigger point as they call in some neo-magic (I am referring to chiro or something) is –why do we have to call it as trigger point and not tenderness. There are some half baked studies which looked into the histopathology of it and proven- well we don’t know for sure. However, there are also many studies which have consistently proven that reliability of finding them poor at the best. The next issue with the word release- what the hell is wrong with us to call something as release. These words come from a magical treatment called chiropractors – who studied magic rather than physiology when they wrote the term. However, we now are in the era of -free or easy access to knowledge, and we should know better. Muscle or pain is not something you release, it is such a complex phenomenon it is scholars are grappling with it for many years, but we are just, “I released the trigger point and the patient is alright”. This reflects very poorly on worth, we are more intelligent then that. 

                So, pray what should we refer to ask my friend? Well, the muscles relaxes, beautifully named as “Hold and relax” by Knott and Voss. Relaxation is a phenomenon of the muscle- not release. As for trigger point, well pray –Sarwathi visits us and we all read medical literature other than Facebook posts.

Of course there are 100s of therapist who are going to say- well this guy is a moron, I have seen it, I have seen people getting better etc.

     

2.       Bone has eroded- (you know what we say in our vernacular). It is high time we talk about back pain, OA as a disease not as pathology. Talking it as a p athology makes you want to change the pathology, it creates so much anxiety in the patients mind. We need to have a better language in patient education regarding these diseases. Just, keep the x-ray or MRI in the cover rather than seeing it.

3.       Facebook- it is a proper noun- it cannot be called as முக- நூல்- come on people Hariohm is Hariohm in any language. Thank god we did not translate- google,  cognizant (which again can be translated unlike google)

4.            

My 2 cents on associations of physiotherapy

I usually don’t write about any of the associations in India or Tamil Nadu (TN). Reason one, well I have a life. But this Saturday afternoon, did not have anything to say so- here is my take on our precious associations.

The first thing I find in TN is there are 2 many associations. The general feeling I get is everyone seem to think they are here to lead and they don’t want to follow any one. The second is everyone thinks there aim is more – how do I put it- has a higher purpose.

The first thing I see all the associations do is –well this is in vogue for the past few years – is conduct a National conference. I don’t have anything against it – but I can distinctively remember in the late 90s we all complained that is what IAP did and nothing else. Well the all the associations have fallen into the same pattern. As we say in non-linear theory- they have all fallen into the same attractor state.

The next thing I remember what all the association meetings were about:

1.       Getting government job

2.       Getting a council

3.       Talking bad about-The Man (the one person who is stopping  us from achieving the goal)

I have not gone to any meeting for quite some time but, I am assuming this is what is discussed and also from all the cry babies writing in face book.  Well what is wrong you ask me? Well don’t worry any of the people who took the time to read this is going to get it. We are more in numbers and the government jobs are never going to enough. Please understand medical economics if you are one of those “leaders”. The government’s policy on health is complex and it depends on burden of illness, resource and who can lobby well. So don’t be gullible in thinking 10- 200 people are going to get you to change all that easily.

Getting the council, Well a must need for PTs but it is not a panacea for all our woes. It is not going to bring more jobs, more money, not change your salary if you are working even in a college. Come on people read market economy; we have a right wing government in the centre and a centre to right in TN.

Well not writing about the last one because- I may be the man in the next meeting who is stopping you from growing.

What do I think associations should do?

Well the good things first- I see some association doing clinical meeting or CME. AS you can imagine I think that is a wonderful step. However, my personal opinion is get people from your own city, own association to do the talk. (This is also for the conferences) Why call some idiot from Mumbai or some place else).

Lots of associations have a dedicated people –who are leaders and follower- but I just can’t get over the feeling there is a lack in understanding of rudimentary things. I can remember being like that also after when I came out of college. Use them for something constrictive and think real issues- like training us to do be first contact practioners before asking for that.

Stop telling us diploma is bad, correspondence course is bad- of course we know that, more importantly that is how most of the regular colleges are running. Sad part is some of the “leader” have got there degree by not stepping into the college even to use the loo.

Stop being talk shops. I see many of the association becoming talk shops-getting the troops rallied up all the bull shit but with no substance. The common thing I see people talk is the universal cliché since Marx times- “Unity”. When the great Marx said unity he wrote a 3 volume book- which after trying for 7 years could not understand it- sold it back to the old book store. But most of the time when I see therapist say it is without doubt- without any substances. Why do you want us to be in union? Fight for what? What right am i not given? What is your goal? If your goal is get united and fight for unity, justice, get a council, get us jobs- well may be I will join justice the league  and fight crime at night along with superman et al.   

Of course there are also other association/ cults in this mess- the NDT cult, Mulligan cult and the overall manual therapist cult-well don’t get me started on those idiots.

Disclaimer: I have participated in some associations functioning before realizing –what a waste of my energy and intellect.

Homer Simpson- Old people don't need companionship. They need to be isolated and studied so it can be determined what nutrients they have that might be extracted for our personal use. 

What’s up with Supraspinatus?

What’s up with Supraspinatus?

I always think supraspinatus epitomises what is wrong with physiotherapy.

Well what is the connection between Supraspinatus and physiotherapy? Well let me start with the story of supraspinatus. As we all know it is small muscle which is oriented horizontally and present around the top of the shoulder joint. 

The problem starts when we ask the question what is its action. Invariably the answer is initiator of abduction or works up to 15 degrees of abduction you stupid is the answer. It is how the anatomist taught me when i went to college (long time ago) and it is what is taught now also. The anatomy book we refer still says this as the answer (and they will not reply me for all the mails I have written regarding it).

Well what is wrong with the answer- well from the 60s people started identifying supraspinatus as abductor rather than a specialised initiator. In his classic book “muscle alive” Basmajian wrote in the 80s how we are repeatedly mistaking supraspinatus as an initiator rather than as a synergist in abduction. Other anatomy books have followed suit including text books like “wheelers text book of ortho”, biomechanics books etc.

However, I am not sure why PTs, the people who are concerned with movement seem to make this wrong assumption after all these years. Even experts! in sport and manual therapy are making this error.

It begs the question-does supraspinatus a symbol of our antiquated knowledge?

Homer Simpson: Lord help me, I’m just not that bright.”

Wieners and other cry babies and their diagnostic tests

Wieners and other cry babies and their diagnostic tests

Well this time I am writing about my favorite subject- criticizing anyone- but this time medical practice in TN (including fancy nonsense like sidha, homeopathy and all the pathies including Physiotherapy).

I am writing this after a TV program in TN (which fortunately I did not watch) which created a controversy and wieners in the medical profession are crying about it (including PTs ).

The first relates to overuse of diagnosis in practice and getting substantial illegal money for it. This again is also prevalent in PT and other pathies. I am not going into the issues highlighted in the program as we all know it is an open secret -that for every medical test the medical practioner gets at least 50 % as illegal black money (it should not be called commission- as it might be a legal tender for example what a real estate agent gets).
The first issue in requesting a diagnostic test is that it should increase your probability of the possible disease. Also we should have an assumption (a pre-test probability) that this person may be suffering from this particular disease and then do the test. You should not do it wily nily on all the patients. For example you do a test for malaria on patients with symptoms like paroxysmal symptoms of fever shivering body pain etc. You don’t do it on all the patients who come to the GP with fever. Or you don’t do preg-test for all the women who enter the OBG clinic.

However, this is what happens in case of LBP- either a MRI or a X-ray is ordered by –well any idiot with a pen and thinks he/ she is a doctor (which again includes PTs and other nonsensical profession like sidha etc). Why pray is a problem? - The biggest problem is we are going to have over diagnosis and lots of false positive. Second is the harm the patient is exposed to- the X-ray is not a torch light. Third is harm of teaching an anatomical or a pathological model of pain which is the biggest harm i presume, as it might impede the prognosis of the patient.
The second issue is a test (like an x-ray or MRI) should change your treatment after the patient undergoes it. For example, if you have a patient with LBP and you are thinking of exercise and some passive treatment like IFT or manual therapy after the patient has got an x-ray or MRI the treatment should change. I am pretty sure after X-ray none of PT management is going to change (if there is no red flag). A second example can be an x-ray for OA knee patient- will the treatment change because the patient has a joint space narrowing or osteophyte- the answer is no for any treatment. However, when a patient with OA is not getting better, his joint movements are very restrictive  and when you are contemplating surgery then you need a x-ray as it may influence your change in management- that is joint replacement.

Hence, most of the time if you are ordering for an x-ray – you should be thinking – does this patient has a red flag. That is we should be having a big concern or suspicion that the patient is having a systemic disease and that is causing the pain. Next if you are ordering for a MRI- probably the patient is being posted for surgery- as you can imagine surgery is different treatment than conservative management.

So cry babies in medicine should first learn medical theories and best practice methods and then cry wolf. The next post we will see why screening is good for only doctors and hospitals and not for patients.

So for medical professionals the lessons are if most of your patients with pain are getting an X-ray- you are over utilizing diagnostic tools. If you most of your patient are getting a MRI (for pain) the you are not only a moron you are also a cheat and a criminal (as you are also getting illegal money from the center)

For patients-  

1. Ask your doctor why and how will the “test” will help me in getting better

2. Even for a simple blood test ask the 101 question you ask you cable operator when he comes to collect the paltry sum of 100rs

3. Tell your doctor to f!@# off he tells you to get the test in his favorite lab-well go and complain in a consumer forum or just write nasty things about the system on the net- see what happened when a uneducated said nasty things about doctors

4.  Remember medicine is also a business not a noble profession (that was 30 years back) so shout at them when the service is poor or you are not satisfied- as in case of with your mobile phone operator

5. Read consumer summaries and guidelines issues to reputed sites like Cochrane (http://www.thecochranelibrary.com/view/0/index.html)

Reference:

1.       Appropriate use of diagnostic imaging in low back pain: a reminder that unnecessary imaging may do as much harm as good

Homer simpson: “What's the point of going out? We're just gonna wind up back here anyway.”

A rhetorical question

A rhetorical question

A favorite question of mine is- if you a patient has say LBP or PA shoulder should the patient be seen by a therapist and asked to get an appointment for 5- 10 days or get a package ( up to 15000rs in chennai) until endpoint of the disease or pain.

The question is why should they attend a PT department daily rather than taking some pain killer and doing the exercise at home if needed? Isn’t it cheaper to spend 20 rs on some NSAIDS and do some exercise at home!

Here are some of the answers I have got from PTs. They have to attend a PT session because of-

1.     Is it because- supervised exercise is needed or more important?

2.     US, SWD, IFT, manual therapy is better than NSAIDS

3.     The adverse effects are less in PT than drugs (really)

4.     Others- please specify---------------------------------------

Please comment you answer.

Love

Hariohm

If they think I'm going to stop at that stop sign, they're sadly mistaken! --Homer Simpson

Research Fraud

Research fraud:

The other day one of my grad students asked e a question-“how do you know the data the put up in research study (journal article) is true”. Even though the answer for the question can be simple from- I don’t know, to  complex “well the researchers will have academic integrity” and so on.   That got me thinking- can i answer the question of do i believe the data- in the Indian context. So, I just thought -well let’s just think about it. 

I went and looked into some research studies published in some journals from India (especially PT journals). I have some knowledge on how Phd is done in our country. I have been also privy to some raw data also collected by people who are doing Phd or finished it.  From these i can honestly say many of these data look very iffy and some downright fradulent.

Why- well many of them send their PG dissertation and it takes few days to publish in some of the Indian journal especially in PT or rehabilitation.  Again, you may ask what is wrong with it. Well most of PG dissertation is just cooked up data sitting in the loo or while watching cricket match. 

We all knew for long time PG data many a time was cooked up. We all just sat there and watched as PTs started cooking data and plagiarising the content. We all thought well this is victim less crime- no one is hurt and the guy wants to finish the course.

However, this all changed with many of us got into the rat race of publishing. People started sending their dissertation, data which they dreamed up to some journal which wanted content desperately.  PTs doing PhD – well most of them just write some numbers and they also publish it.

 The mafia of cooked data (the drug peddler if you think them as cooking meth) and the journal (the police who have to control the peddlers) became strong. Along come databases like CINAHL, PEDro etc which started to index these journals with it came, the victim in the crime.

As more and more people started to look into all the published data either as part of EBM practice or doing a systematic review, these data (cooked or uncooked) became vital.  What happens if i want to look into say- Burnstromm  or electrotherapy for pain- most of the data which is published in these journals give a positive result (sometimes huge) unlike the other published data.  Akin to saying crows in my town are white unlike other crows which are black.  This skews the answer or for people who do SR.  Which by the, way ruins the whole idea of science of medicine and EBM. We may also be coming to the wrong conclusion, a useless treatment like Brunstrom for stroke as useful.

PTs in India must develop – research and academic integrity and stop the crime we may perpetrate in making medicine unscientific.   The editors of the journals should be more vigilant, tougher peer review moreover; the PTs who know he/she was fraudulent in his/ her data collection should never publish it.

Facts are meaningless. You could use facts to prove anything that's even remotely true! --Homer Simpson

love

Hariohm

Random thoughts

Random thoughts 

The natural question I get when I turn back – is physiotherapy evolving in India?  When I went to college the treatment was simple, do your exercise – no fancy names (but of course the exercise where not adequate), and over emphasis on equipments.  Neuro-rehabilitation, was more advanced in the 90s at least were I went to college. Even though there was undue importance to passive movements. The treatment was always active, “Hands off” when making them walk and stand, train upper limb activity. We even have community walking as many of my classmates could agree. No nonsense key point, no synergistic movement nonsense. Back pain surprisingly my friend a EBP in LBP would have been proud, - consisted of exercise, and (over emphasis on) SWD (which come to think about has as good an evidence as any other up to date fancy named therapies like- SMT, MET and what other crap workshop you attended last week.

But sadly all went south as more and more crap crept into our thinking. Many PTs seem to think yes- we are learning manual therapy –written by every idiot and intelligent people. The Idiots I mean are the osteopaths and chiropractors and well some PTs. NDT, PNF, this exercise that exercise, eccelctive approach- that horrible quotation- “these are my tools in my tool box” , 1001 special test (hate the word makes me feel I am ordering dosai in the mess I ate when I went to college- I special dosai).

But sadly, zero importance is given to physiology, motor control ideas and theory, pain theories etc.  The other day I heard a idiot- a instructor in NDT saying normal movement of gait need core muscle strength- I was about to say to him- get the hell out our country and stop making my people more dumb (we are there to help them not learn anything keep them dumb we don’t need any help from you). Well he is an expert in CP- good save the children of India from NDT trained idiots.  

Let’s get back to basics- I mean emphasis- on educating the patient, active treatment, hand off the patient and understanding the disease and patient rather than some point or techniques.  

It's all over, people! We don't have a prayer! -Reverend Lovejoy  from The Simpons

The intelligent therapist guide to being intelligent

The intelligent therapist guide to be intelligent

In the ever increasing list of workshop starting from pure crap like chiropractic, osteopathy and dry needling (acupuncture masquerading as new age Babel)  and modern pseudo-science like NDT, SI, MET etc. how to can a intelligent therapist keep his sanity?

These are the check list the “The Indian Centre for Evidence Based Neuro-Rehabilitation” ICEBNR people have come up with before and during the workshop you need to look for:

1.       Read the brochure – if the “expert is certified in the technique” other than a university well just avoid it- probably a waste of reading beyond it. Universities are leaning centers (even some of it is useless) and centers which certifies you are well you can fill in the blanks

2.       Alternate in treating, holistic are all catch phrase of modern  pseudoscience science- be careful

3.       Become a expert – after doing the course- well if you see the expert who claims that- kick him – no one can become a expert in anything in 2 days or 6 weeks except my cat which became a expert in shiting in 2 days

4.       "Hands on" are more than theory than kick yourself for wasting your time. Remember any monkey can learn the technique, but you can learn or teach science to a monkey

5.       See change in the same day, immediate relief- these are red flags if the expert or brochure claims this.

6.       Ask them for evidence- if they quote an article –go and read them- most of them will say the technique is not working - they have not read it so they are depending on you to not read it.  Classical example – go and read the NDTA associations page on evidence most of them will say it is not working except some half ass study they themselves did which says well we are not sure.

7.       Remember if the expert has done 25 courses in 25 countries that will not make him an expert automatically.

8.       If they claim it sure will work- and give you didactic advice be careful

9.       Red flag- if you haven’t heard of the physiology in your life- example cranio-scaral therapy- well it is a suture idiot – we know it can’t be moved. Kick him in his nuts.

10.   Don’t keep your mouth shut and come out and start complaining – start asking questions while in the course.

11.   Remember it is not rude to disagree with the resource person – it is good manners to keep the resource person and yourself honest.

12.   Well – the easiest of all things is to learn by yourself and all together not listen to any half assed expert.

Operator! Give me the number for 911! – Homer Simpson

A ode to my teacher

A ode to my teacher

I used to think a teacher was a person who taught you stuff like stroke rehabilitation, Math, etc. Then i went to college and met Mr. Siva Chidambaram. He was my lecturer and the junior most of all my teachers. He was sort of a poor teacher when he went and taught in the class room. He would not write in the board, could not effectively hold the classrooms attention. However, when he taught bedside clinical issues he just transformed into Stephen Hawking explaining black holes to novice in theoretical physics. He was clear in his views made you want to do it then and there what he was asking to do.

His greatness was that he could teach me stroke or SCI, but the way he would make you “want” to learn more. He was telling us to always look forward with theories and techniques.  He was teaching us MRP in 92 when most of the world taught it meant a tyre company.  He would tell me to try mobilisation of the knee joint using techniques he and i saw in a book.

The best anecdote about my beloved teacher is when i started to do my ortho project in 5 semester for my under graduation.  Unlike know, those days the topics were selected by the teachers and we have to select one through lot system. Presto i pick Potts fracture. My teacher who was man bent on teaching me told me to go and refer “Watson and Jones – fractures and injuries. He added that it is the bible of traumatology and I should read this book for the project.

I go and open this book on Ankle injuries and in the first few pages it says- Potts might have made a mistake and blah, blah and they concluded the better terminology could be “Ankle injuries”. I go and show it to my teacher and he says well we have to change our title for your project. We go and show it to my professor after protesting for some time she also agrees. The lesson is they were able to change their views even when a lowly 5 th semester student showed some literature.

Sadly nowadays the teachers will not change their views even it came and hit them on their face. Some clinical are beyond repair they just won’t look for evidence. The standard answer they have is well it works for me and my patients. It is like saying to Newton huh! My apple went up so i am not sure your theory and proof is good enough for me.

Love

K Hariohm

Today’s homers quote

BARNEY: Hey, Homer; you're late for English!

HOMER: Pffft, English. Who needs that? I'm never going to England.

Film songs theory part II

In continuing with my “film song theory”, the other off shoot of it is the so called ecclective approach. Some therapist can’t leave their song and dance routine they have come up with this idea called as ecclective approach.
What pray you may ask is ecclective approach? Well you take a bunch of treatment written before man went to moon and mash it all together and think well i am a genius.  The treatment commonly mashed together are PNF, NDT, SI, Brunstromm and other initials i have missed.

What is wrong with that you ask, adding you take the good from all the treatment? For example i will use NDT when the patient cannot move, use stimulus ideas from PNF and use what the heck cranio-sacral therapy to well make a fool out of me. The problem is these techniques were once the cutting edge in science- well in the 70s and 80s (of course cranio-sacral therapy was nonsense even then) but like everything else time and science changes.

These treatments physiological validity and clinical effectiveness has been over time been proved to be very limited. Hence putting two or more treatment with iffy evidence is not new improved treatment. The garbage ladies of our street collect the garbage from each of our house and put it in a large bin at the end of the street. Putting it all together in the end of the street does not make all the garbage into gold it just makes it into bigger garbage.

So we need to move on make movies without songs like the one Adoor Gopalakrishnan makes. We need to come up with new ideas, use ideas which have clinical evidence- proven and use it with our experience and the most important organ of the therapist - well not the hands, the brain.

Every blog i am going to close with a quote from hero- Homer Simpson

Facts are meaningless. You could use facts to prove anything that's even remotely true! --Homer Simpson

 love 

Hariohm

hi

Hi
 
   After countless push from Prakash V I am starting my blog today. As this is going to be my first I am going to make it simple and non-controversial as possible.

I was having my usual weekly conversation with my friend on –well what else physiotherapy and overall lack of scientific backing for some of our physiotherapeutic techniques.
The question in our mind was why we are unable to move on. You learn something in a particular point of time say manual therapy or NDT and when you see the idea is outdated or the treatment is plain useless we still can’t get over it. Even intelligent therapists seem to be stuck in the time warp. I have seen experts in neurology unable to come to terms with moving of science and time. The common example I use to stress this is the prevalence of normalization, thinking purely mechanical and searching for that one treatment which will bring about the magic touch and heal. (Will write about “hands on” some other time.)

One of the theories we came to is “film music theory” of why we wont move on. The theory is fairly simple in Tamil film industry we have serious film makers who want to make neo-realism movies, but can’t get out of the idea of not having music. Even though it not in the “proper” to have songs in neo-realism they can’t seem to do it because of the 100 years of tradition have making crappy movies with songs.

Likewise in this age of evidence informed practice (EIP) we still can’t come out of NDT if you treat children with cerebral palsy.  This is exploited by the companies which sell these course- and they have “certified tutors”- whatever that means (still can’t understand to teach some techniques why you need to certified- that to a treatment which can be taught in 15 minutes). They charge up to  2 lakhs if they come in a plane from North America- they still teach you the same crap they taught you in your UG- well no one learns anything in PG.

Why this fascination with un-scientific courses, is it because we have to have songs in our movies come what may.