Over the years, I’ve seen the words “evidence-based” used to justify a lot of concepts I find dubious. (Trust me– I saw some pretty ridiculous things during the time I worked in a mental health group home).
This article from Paul Ingraham at PainScience.com in favor of moving from evidence-based to science-based medicine was music to my ears. I realized that, although I hadn’t consciously thought of it in those terms, advocating for that shift has been one of my motivations for working on this blog.
A lot of the treatments for fibromyalgia sufferers might be “evidenced-based,” but that doesn’t mean they shed any real light onto its causes. For example, an “evidenced-based” course of treatment for someone with chronic pain or fibromyalgia might be cognitive-behavioral therapy. It’s true that multiple studies have shown CBT to be helpful for patients with these conditions.
However, I don’t believe it’s reasonable to infer that because CBT has been shown to benefit fibromyalgia patients, those patients must have had an underlying psychological problem in the first place which contributed to their fibromyalgia.
To me, that’s confounding variables.
It makes perfect sense that someone with chronic health problems is going to appreciate having a sympathetic person sit with them, listen to them, and teach them new coping strategies. However, this does not mean that fibromyalgia or related conditions are caused by depression or anxiety. It simply means that therapy helps patients feel better.
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What I try to do on this blog is to present the scientific evidence in favor of what I’m arguing. That’s why I am always linking to academic articles. Even though I know people don’t always have time to read them, it’s important to me that the citation is there.
It blows my mind that there are still practicing medical professionals out there who are unaware of all the research that has been done on the complexities of the nervous system, and how people experience pain. In my opinion, the research that has been done on the process of central sensitization is a lot more convincing than the research that has been done on the overlap between mental health conditions such as depression and anxiety and fibromyalgia.
For one thing, it makes sense that you’re going to find a higher rate of depression and anxiety among the chronically ill. I don’t know why anyone is surprised by this. To me, it makes perfect sense that those suffering in chronic pain and discomfort would experience an impact on their mental health. It’s a chicken and the egg problem, and I find those studies relatively meaningless.
For another, the people who write these studies apparently don’t know anything about the process of central sensitization. They appear to be completely unaware of the ways our nervous systems can physically change in response to chronic pain, in a way that is beyond our control. Physical abnormalities have been found not only within the brain but within the spinal cord of chronic pain sufferers.
To say that depression and anxiety are responsible for chronic pain is to focus on only the tip of the iceberg. If the people who published these studies would at least acknowledge the rest of the iceberg, I would be able to take them more seriously.
But it seems that academic knowledge is too compartmentalized. Some people go into psychology and study people’s moods and thoughts. Some people go into neurology and study the nervous system. Even the people within neurology end up specializing.
This is why I am inspired to see people beginning to criticize the concept of “evidenced-based.” I’m tired of people throwing those words around as though it means what they are doing is automatically great. There is a difference between evidenced-based and science-based. When you can see physical abnormalities in the brain of a chronic pain sufferer under a fMRI, that is science. Assuming that people with fibromyalgia must have a problem with depression because psychotherapy makes them feel temporarily better is not.
Anyway, that was a bit of a rant (but I’ve been told my rant-y posts are some of my best!).
Do you agree with me? Disagree? Let me know your thoughts!
Wild Juggler
April 1, 2013 at 3:45 pmExcellent post! I know I definitely prefer science-based medicine over evidence-based medicine. EBM doesn’t even consider prior plausibility, how ridiculous is that? With the EBM approach, something as pseudo-scientific as homeopathy “deserves more research”. I regularly read Dr Novella and Dr Gorski. I’m glad you posted this.
sunlight in winter
April 1, 2013 at 4:29 pmThank you! I’m glad my post resonated. And yes, without prior plausibility, what’s to separate the real treatment from the placebo? Nothing. That’s also totally ridiculous about homeopathy needing more research.
jezzybel
April 1, 2013 at 10:39 pmThe way we are taught (allied health in Australia) is not just to use evidence-based medicine, but BEST evidence. So, there might be a couple of studies supporting X, but you can’t stop there; you have to dig through the literature, and if you have several randomised controlled trials contradicting X, and/or if findings do not have theoretical support, you’re out of luck! We also get taught to be aware of the fallibility of the scientific method – the decline effect and the relative meaninglessness of null hypothesis significance testing is beginning to be given more attention.
In terms of the chronic pain and mood disorder thing, a lot of people overlook one of the basic premises in science; correlation is not causation! So that’s just bad science. You need prospective longitudinal studies to determine which comes first. And even then, similar neurotransmitters are involved in chronic pain and mood disorders, and stress hormones caused by environmental factors can cause physiological changes in nervous system function, and these are inevitable confounding variables. So pre-existing mood disorder followed by development of chronic pain may just mean that the person has a system more susceptible to both problems (because of whacked-out levels of a particular neurotransmitter, and/or too much environmental stress). You still can’t say the depression *caused* the chronic pain without eliminating all other possible causes.
For me, the more I learn about good science, the more I realise it doesn’t – it can’t – have all the answers at this point in time. So it frustrates me to no end when scientists pretend it does. I think it is absolutely, definitely our best starting point, but to act like it’s set in stone because one (or even a dozen!) study supported a finding is ridiculous.
That got extremely long and ranty. Sorry 🙂 Clearly this is a topic I’m also passionate about!
sunlight in winter
April 2, 2013 at 12:13 amHaha, no need to apologize! I thought your comment was interesting. I always enjoy hearing your thoughts, as someone who is learning about this sort of topic in an academic setting. I didn’t really study healthcare related topics in college.
Much of my annoyance with the term evidence-based has to do with the way I’ve seen it thrown about in the mental health care system. The agency I worked for advertised itself as using “best practices” and “evidence-based techniques,” when really, the place was just a mess. That’s part of why those terms have been so cheapened for me. More horror stories on the group home later…
jezzybel
April 2, 2013 at 12:59 amIt definitely gets thrown around too casually. It’s like, hey, I found a single obscure journal article supporting my position, so let’s call it evidence-based! No. Not cool. And it gives a bad name to the people actually doing it properly. Frustrating.
jezzybel
April 1, 2013 at 10:43 pmOkay, and just to make it even longer:
In terms of clinicians not knowing much about pain, surveys of prelincensure health professions pain curricula in Canada showed an average of 13 – 41 hours dedicated to pain (in about 1/3 of unis, 2/3 couldn’t quantify because they didn’t have dedicated curricula). That’s 20ish hours in 3+ years of training. A survey from the UK was similar. And there’s little time or incentive for health professionals to continue their education once they’re licensed (at least in Australia, continuing professional development is mandatory but unpaid, and can be on any topic, so only those interested in pain would pursue it). Canadian vet students got twice the pain education as med students. I nearly cried.
Canadian article is here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2807771/
A report on the UK study is here: http://www.britishpainsociety.org/members_sig_edu_short_report_survey.pdf
sunlight in winter
April 2, 2013 at 12:15 amThat’s crazy about the vet students. Wow.
jezzybel
April 2, 2013 at 12:56 amI know! I was like, great, my cat has a better chance of having its pain managed appropriately than I do. It seems beyond ridiculous that chronic pain is the most common presenting problem for GPs, is the third most expensive health problem in Australia (similar for other developed countries), and yet pain is less than 1% of the medical curricula. Whyyyyy.
sunlight in winter
April 2, 2013 at 5:14 pmUgh… I wish I knew. Maybe it’s because people have an easier time feeling sorry for animals in pain, whereas when they look at a person in pain, they’re more likely to think “she’s just exaggerating” or “it’s her own fault for not doing her exercises.” I blame Freud.
lucybythesea
April 2, 2013 at 5:49 amThanks for pointing this out. Did not knowe. 🙂
sunlight in winter
April 2, 2013 at 5:14 pmYou are welcome 🙂
failedadventures
April 2, 2013 at 8:44 pmThere was a really great issue of Pain Pathways magazine this month- it covered a lot of what you write about. One of the things I constantly struggle with as far as fibro research goes, is the constant pushing of pills. I have had bad reactions to various ‘fibro’ pills so much so I refuse to try any more. Plus, long term use of a lot of these pills actually damages your nerves anyway!
But thank you for your logical and insightful posts. I always look forward to what you have to say
sunlight in winter
April 2, 2013 at 10:04 pmThanks for the compliment 🙂 I’ve never heard of Pain Pathways before; I’ll have to check it out.
I’ve never had any luck with “fibro pills” either. I think one of the main reasons these medications get so much attention is all the money the pharmaceutical industry has spent on marketing them. That’s why we, as patients, feel we ought to try them, and why our doctors feel they ought to prescribe them. It probably has a lot to do with why researchers have been eager to study them, as well.
crossinh
April 3, 2013 at 4:04 pmIf the medical profession got any more compartmentalized, it will lose all relevancy. It is sad that patients do not know which doctor to see for a given problem. General practitioners are not being trained adequately as gatekeepers; specialist go as far as ignoring any symptoms they feel are unrelated to their specialty even if they are relevant to the patients’ conditions. It is a sad world we live in…
sunlight in winter
April 3, 2013 at 6:38 pmCompletely agree!
brain injury self rehabilitation (BISR)
April 6, 2013 at 9:09 pmWhy do healthcare professionals not believe the patient? It is there job to listen and understand, and neither are happening. Hence, patients are struggling to find the solution to be comfortable and by this is destroying many lives. It’s a sad situation.
Even if more time was allotted to pain in the educational system, would they be listening? It’s been my experience with colleagues that when they finally endure a problem of their own they begin understanding and it shouldn’t have to be that way! Obviously, something is missing or do healthcare professionals just become immune to others problems when they should be problem solving for them. Do they forget what their job is?
sunlight in winter
April 8, 2013 at 2:27 pmThat’s a really good point, that even healthcare professionals don’t necessarily have much empathy for this kind of thing until it happens to them. Yes, I think sometimes people do forget what their jobs are… or they never really understood what their roles were supposed to be in the first place.
brain injury self rehabilitation (BISR)
April 6, 2013 at 9:09 pmWhy do healthcare professionals not believe the patient? It is there job to listen and understand, and neither are happening. Hence, patients are struggling to find the solution to be comfortable and by this is destroying many lives. It’s a sad situation.
Even if more time was allotted to pain in the educational system, would they be listening? It’s been my experience with colleagues that when they finally endure a problem of their own they begin understanding and it shouldn’t have to be that way! Obviously, something is missing or do healthcare professionals just become immune to others problems when they should be problem solving for them. Do they forget what their job is?