Thoughts on a recent Journal of Clinical Oncology paper: Amount and Intensity of Leisure-Time Physical Activity and Lower Cancer Risk (December 26th, 2019).

On 16/01/2020 Physiotherapy New Zealand shared an article from Healthcentral.nz which appears to have been written by the New Zealand Herald – image of the article header below:

Click to read

The article was also reported on by The Washington Post on 13-01-2020 .

So…. What’s the beef? This all sounds great right?

As a very strong advocate for “Exercise For Life”, you might be wondering why I am doing a review on something that sounds “right up my alley”. Well, it is important that we have a look at and discuss the good as well as bad information that is out there and try to explain what this actually means for you (and/or your clients/patients).

For anyone who would like to read a copy of the full text article, it is available at this link (not even behind a paywall) – the Data supplement is available here.

So, to get started, we will start at the top – the numbers.

• 1.7 million Americans will be diagnosed with cancer each year – that’s out of a population of of 330 million.
• This is a rate of 515 people per 100000pop. for all cancers (as a basic calculation – not ASIR) but the official age-standardized incidence rate (ASIR) for 2018 is noted on the World Cancer Research Fund page as 352.2 per 100000pop.
• New Zealand (where I live) has an ASIR of 438.1 per 100000pop.
• Australia sits at an ASIR of 468.0 per 100000pop. – the highest in the world.
• Europe has rates as high as 373.7 (Ireland) and as low as 242.8 (Lebanon).

Why is this important to discuss? Well, the study used 9 cohorts (large groups of people), 5 from America, 3 from Europe and 1 from Australia, all between the ages of 32 and 91, so you would expect that the cancer rate should sit somewhere between the worst 468.0 and the best 242.8 of the possible cohort participants.

In the study, they only looked at 15 different types of cancer that were associated or may be associated with activity, not all cancer types. They reported 50,620 cancer diagnoses (of the 15 types assessed) in a group of 755,459. That is a per 100000pop. rate of 670. That works out to be a 43% higher incidence rate than the highest ASIR in the world – and while you can say “this is not an ASIR”, you would be right and the process of standardising the data is statistically powerful and would no doubt alter the rate, but, it is also important to note that this rate was only taking into account the cancer diagnoses that the study was looking at. My main concern here was that there was little discussion of the apparently high incidence rate within the cohort groups and what this meant for the outcomes of the study.

The outcome

The point of the study was to look at activity involvement and intensity and see the effect that this has on cancer risk. This is where the good news is – for a large portion of the cancers included, there was a statistically supported decrease in risk with activity that met the recommended physical activity guidelines (2.5-5hours per week of moderate activity). Here is where I put the note that “statistically supported” simply means that the activity resulted in a decreased risk, not that the decrease was a large/worthwhile amount – more on that later (under “Results”).

With the popularity of HIIT training these days, it simply wouldn’t do to miss an opportunity to comment on higher intensity exercise. So, for those that were involved in higher intensity activity that was associated with a further reduction in risk for breast, colon, endometrial, head & neck and esophageal adenocarcinoma. So yes, it does look like higher intensity training can be useful in this sphere of health too! Although, the relationship was not linear for all cancers, so, if you are aiming for reduction of risk across “the spread”, its not a case of “Higher intensity = lower risk”.

The reality here is that as long as the activity was at least moderate in intensity and for the recommended 2.5-5 hours per week, the study did not find any differences in the type of exercise – so do something that you like/love.

Some of the weaknesses in this study are: the groups were predominantly white (95%) in race and had 53% female (the world is closer to 30% white & 50-50 male-female) and the assessment was a self-report questionnaire (considering the preceding 3 month/12 month period) which I could not, for the life of me, find out when it was administered in the 10.1 year study period, but I assume at the beginning. Given there was no follow-up, it is not possible to know if people continued with the activity at the same levels for the entire study period, and if their levels changed, how this impacted the cancer risk.

Results:

Well here is where the good news is, there was a noted reduction in 7 out of the assessed 15 cancer types between 6% (lowest effect) and 27% (highest effect). Liver cancer had the highest response with a 27% decreased incidence with a normal ASIR of 10.1, and breast cancer was the lowest effect of a 6% decrease with a normal ASIR of 45.91 (2017 data).

So to put this in a real world scenario – while 27% reduction in risk of liver cancer is huge, with a 10.1 diagnoses per 100000 population ASIR, here in New Zealand, this would drop the diagnosis rate from 48 people per year to 35. Now this means a whole lot for the 13 people not being diagnosed in that year, but it does not stop them being given the diagnosis the following year. If you look at it from a simple risk perspective, you would drop from a 0.01% risk to a 0.01% risk (both rounded to 2 decimal places)…… damn…….

Where we look at breast cancer, a 6% reduction in the 45.91 ASIR would take it to 43.16 so a risk of 0.05% to 0.04% per year but a reduction from 2201 diagnoses to 2069 meaning 132 less diagnoses per year.

The important thing to remember here is that cancer is a VERY complex condition to do with genetic coding, cell replication, exposure to chemicals/irritant/carcinogens and other factors. So it is never going to be as simple as seeing huge reductions in risk from exercise, or even exercise and diet as a health approach.

Discussion:

So is it really an awesome study helping people avoid cancer?

• Like a lot of these cohort studies, looking at a large group of people means that the outcomes will relate to large groups too. So yes, yes it is good news for population risk.

Does it say that YOUR cancer risks will be significantly reduced by exercise of a set intensity or following baseline exercise recommendations?        

• Well, probably not.

So should you go out and get cracking with that new year’s resolution to do more exercise, live a fitter and healthier life?

• Of course! Every risk factor you help to reduce is a positive, but it is a risk/reward process. The chances of a HUGE effect are minimal, but the other side effects of exercise (beyond cancer risk rates) are many and mostly positive (improved sleep, decreased pain, improved energy levels etc) so it’s a win/win.

If your goal is to reduce cancer risk, spending a fortune on “health coaches” or trainers for specific programmes will be highly unlikely to make a major difference, but in this case, getting more active (2.5-5 hours of moderate activity per week), no matter what your chosen exercise is, will likely set you in good stead (add in a diet of largely unprocessed foods with lots of fruit and vegetables and you can further “up” your efficacy!).

What can we take away?

So in conclusion, exercise is good for you, and there is real data out there that supports the use of activity in reducing your cancer risk, so get to it, get up and get moving every day, and as a community, we will all see less cancer in our midst.

If you are unsure where to get started and know that you have some risk factors, get to your GP for a review and then engage a well-qualified exercise professional to get you a self management exercise programme with some input to keep it fresh and fun for you (after all, fresh and fun is what keeps you going back to do it).

Health & Fitness

Az

The above article does not represent professional recommendations on treatment or an opinion on any person or persons medical condition(s). It is an opinion piece reviewing the linked research and should be viewed as such.

who is encouraging trainers to be better (or worse)?

Another great post from critical fitness! (HERE)

I believe that the author has repeatedly been told he is “Firm but Fair” and I really feel that articles like this opinion piece do a great job in forcing all of us to “turn the lens on ourselves” & review our practices.

The section in here that really resonated with me was the use of fake titles.

As a Health professional (mandated registration) we have fairly good controls, albeit sometimes a bit too tight (in my opinion), over the titles we can use, so it continually frustrates me seeing unqualified dolts referring to themselves as “Lord God and Emperor of all things health” when they have a short course in exercise prescription sufficient to start a career as a gym instructor.

Anyone who knows me, knows this is what I look like when I see bogus claims – I’m pretty sure Apple used me to design this Memoji

Why am I posting on this and not just sharing it?

Recently I received a bulk email from the Australian Fitness Network where a British Qualified Personal Trainer (Bachelor of Sports Science) was being promoted as an “Epigenetic Educator” as part of a programme that trains “Health Coaches”.

To put this in context, the Australian Fitness Network’s mission statement is to be “the leading source of information and professional development in fitness”.

I contacted the Network by email on May 13th to find out what the basis for this title was:

“As Mr THE TRAINER is being promoted as an “Epigenetics Educator” by yourselves, and this is a budding field in genetic science (in which only a few of the “top of their field” geneticists would be considered competent) can you provide some background as to the formal education that enables Mr THE TRAINER to have a competent, valid and educated opinion on such a complex scientific topic please?”

The response came from Kate Kraschnefski, who is the National Training Manager for the Australian Institute of Fitness, as the official response from the Austrailian Fitness Network. She stated:

“THE TRAINER has a Bachelor of Science (Sports and Exercise) from the University of SUCH THINGS in the UK and is the Managing Director – Health & Fitness for A COMPANY.  A COMPANY is a global health and wellness system that is underpinned by evidence from a range of scientific fields.  It has proven to be a successful tool for many fitness professionals who have achieved great results with their clients, which is why we invited THE TRAINER to be a guest on our podcast.  You can explore the science behind A COMPANY here https://wherewetry.to.sound/sciency”

It is worth noting that there are no peer reviewed or appropriately published articles on the website that was linked and some questionably loose definitions of science and the supposed included concepts (which include Ayurveda and TCM which couldn’t be further from science if they tried). I have removed the trainer & company names from the quotes as the issue here is about the promotion of fake titles, not the substance of the company themselves. Block Capitals and bolded test are my additions as replacements.

It is really important here to break this down into what criteria the Australian Institute of Fitness and the Australian Fitness Network deem as reasonable to claim a title, apparently, it is:

 being a director in a company (credible or otherwise) that wants to call you that title, so it can use you to sell a product that people believe works for them (post hoc ergo propter hoc).

This is just the big business version of a self employed Personal Trainer picking a title to sound “more special” than the rest.

Why am I bringing this up here? Well, as is so clearly pointed out, we need more “Good Trainers” out there and less bad ones. So, while  Critical Fitness’ aspect of a “Bad Trainer”, claim false titles, is being promoted by Kate – the National Training Manager of an institute of study and the representative of the Australian Fitness Network in these issues – what hope do we really have?

An example of how a Personal Trainer justifies their change in title:

One such “Health Coach” in my local area notes that they were a personal trainer who was struggling with the nutritional advice that they were able to provide to their clients (IMPORTANT: this is not a surprising statement given providing nutritional advice is generally outside of the professional scope of a personal trainer here in New Zealand). To remedy this they went looking for a “new qualification” to “give them (their clients) all the answers”.

This demonstrates a significant lack of knowledge about the health sector, (no one qualification has all the answers – any that suggest that they do are clearly bogus).

The answer they chose to this was (no, not getting qualified as a dietician)….. they completed a “Mastery Series Weekend” to sell a product (that does offer all the answers, to, well, literally everything) – this is NOT a reputable qualification and is comparable to completing your training to sell Tupperware.

The best bit? You should see how this “Health Coach” charges ($599 for a subscription to a cellphone app, an assessment and 6 weeks of support including a Facebook group) – far above what their Diploma in Fitness would normally support you paying for their time.

It is most important to remember: These people are NOT health professionals.

Image Credit: First10EM

The take homes:

• Avoid the “Health Coaches”, “Master Trainers” and those looking to have an answer to every question – if they don’t even know that they have a lane, how can they be expected to stay in it?
• Just because someone is endorsed by a training institution does not mean that everything they are selling is within their scope of practice.
• Bias affects everyone, even those who should know better – this is not solely an issue with the Australian Fitness Network, but bare it in mind before you head off down the rabbit hole with any professional body.
• If there is someone out there selling a product as an expert or educator – they should have university or qualifications authority recognised qualifications in that area of specialty.
• “Heath coaches” should have a health sector qualification, be registered with a mandatory registration authority and working within their mandated scope of practice – if they are not? They have no obligation to you, your outcomes or your health.
• Demand better from your trainers and get yourself a great one! One who has a collaborative network of other trainers and real health professionals who can step in to help where they don’t have the qualifications or expertise.
• Remember, a great trainer may be the rose amongst the thorns, even the “professional” bodies seem to want to encourage trainers out of their lane…… for the life of me, I just cant figure out why.
• To the Trainers – Be proud of what you actually are, what you can do and do it well. If you aspire to be more, get a real qualification, get registered and come join us in the health sector – not as “Lord God and Emperor of all things health”.

Qualified, considered opinion pieces from pages like Critical Fitness encourage and promote the good within the Health & Fitness sector – make sure you are getting behind these people and support what they do for us all – they encourage us all to be better!

Cheers again for the great work Critical fitness – keeping us all on our toes.

Health & Fitness

Az

The might, the intellect and the ridicule of Dr Zubin Damania (ZDoggMD)

Credit: Video Capture ZDoggMD

Full disclosure here, I am not yet a parent, but I must admit, I know where I stand on the vaccination thing – I am strongly pro.

Having a clinical practice right in the middle of a hot bed of alternative health practices, quacks, scam artists, multilevel marketers (some of them all of the above) and the lowest vaccine uptake community in all of New Zealand (thought to be at around 45%) has taught me that these people genuinely have fears about the information that they have gathered when they “Done my research”.

I would say it has me agreeing that those who push these topics for profit (e.g. Tay’s Way) do most definitely deserve ridicule, mockery and shaming, but some others are only doing the best they can with their limited understanding, a fear of doing wrong by their children and a large dose of societal pressure that makes them feel that if something were to go wrong it would be “all their fault” and not just a rare medical side effect.

(Not being able to understand the real science behind vaccines still doesn’t mean you shouldn’t vaccinate your kids – now, go vaccinate your kids).

What happened today?

So while the world is caught between; not caring enough about COVID-19 & Freakin’ out completely and buying enough toilet paper to eat for 6 months…… a video of ZDogg and Tom reviewing a YouTube video by Jubilee, called Middle Ground appeared on my FaceBook feed. The video was entitled “Pro-Vaccine vs Anti-Vaccine: Should Your Kids Get Vaccinated?” and can be viewed here.

While he and Tom were pretty rough in their mockery of antivaxxers (I have not linked their video here as mockery is not my M.O.) there were a few great moments in this video that I wanted to share with you all today.

To start with, a great illustration of one of the major issues with the anti-vaxxer position, and a empathetic response from ZDogg. The following two quotes are from an anti-vax mother discussing her own perceived experience with vaccines and Dr Damania’s response:

Anti-Vaccination Mother:

“I was vaccinated as a child, but my last vaccination was about 15 years ago when I returned to college and I had a severe reaction in that I became arthritic in my hands. I went to many, many doctors and nobody knew what was going on, why it was happening and just shrugged “It doesn’t make sense you’re too young to have arthritis.” And it wasn’t until having kids and sort of digging into my own research for them that a lot of answers started coming out and I think it is unfortunate that a lot of it IS overlooked.”

Dr Damania’s responce:

“The correlation between having a disease and being vaccinated is something that anti-vaxxers confuse all the time with causation. And again, again, this is all, like, data. The emotional truth of it is; she is just simply wrong, and it is sad, and now she is harming her children because of a misconception that she has, trying to explain something that maybe wasn’t super easy to explain.”

Image Credit – Twitter

Now, this is going to sound a little soft and airy-fairy for me, but I genuinely felt sad that, as an uneducated mother, she had the onset of symptoms after she had a vaccination and that it became her belief that she was “vaccine injured”. It is a great example of the post hoc ergo propter hoc fallacy, where we, quite naturally, assume that because one thing happens after another that the first event was the cause of the second. I really can’t help but wonder if this was all explained to her by her physicians at the time. Perhaps she was unable to hear it as she needed (psychologically) to have someone or something else to blame, but either way, whether it was explained or not, she lives in the belief that her arthritic condition was caused by the vaccination.

(If you watch the original Middle Ground video which I linked above, later on the same mother advises that her child has autoimmune issues which might indicate a genetic component, but there simply is not enough information to know).

Dr Damania’s review of the video

In order to cut the mockery and jokes out of the message, I have collated the next few quotes to give you an idea of the take away messages from the Middle Ground video. (don’t worry, I will be touching on the rougher side of the recommendations too).

What ZDogg went on to say

“…what is not bad, and I think I got out of this debate, is the emotional resonance with the anti-vax crowd. They really feel like they have been harmed and they really feel like this is the reason for their suffering and they really feel like telling the world about it….”

“…ok I understand that, like, I see you as a human being, yes, but we’re going to have to do better to figure out how to counter this.”

“But, should we be able to sit and talk about; well ok, your child had a bad reaction, here is one that had the bad reaction, lets talk about it and why I would still vaccinate my child, but I also witness and appreciate the suffering that your family went through.”

“That’s something doctors are unwilling to do, to a large extent, because we are pretty dogmatic, we are pretty conditioned and we are worried it is going to set a bad example.”

I think it is important to recognise these fears and discuss them. They are VERY real for some parents today. Until people learn to trust their physicians again it is going to be very difficult to rid the world of these ill-informed and uneducated opinions.

I am happy to admit, I am pretty short with most anti-vax promoters – given the harm that is being caused, and I do agree that where uneducated opinions are promoted and sold, ridicule and shaming have a role to play.

Personally, I prefer to illicit conversations with questions that point to the lack of knowledge and understanding within the group, and hope that is enough to put some others off or at least encourage them to find a physician that they trust and get some better information.

I need to declare here – I do not work with the suffering and fallout caused by the decrease in vaccine uptake, but I do understand where these next quotes come from.

ZDogg opens the can

“The reason there is hostility, at least, you know, on my platform is, we think that this is a life and death issue for children.”

“Now, the question is, is it shaming and ridicule? Because she feels ostracised already? I think we need to dial it up to 30. I think in society there should be no quarter for running into a theatre and yelling “Fire!”. Which is what these guys are doing, they are professional activists.”

I hope if anything we can appreciate here that we now have diseases coming back and killing hundreds of children, when we thought we had almost rid ourselves of them.

Compassion is important, and trying to talk to people on the other side of this argument is vital to changing the vaccine uptake rates, however, we need to be careful, in my humble opinion, that we don’t tack in the ad hominem approach, just to try and get some extra points on the score board.

The take homes

• Vaccinate your child to protect them and others in your community.
• If you are concerned about vaccine side effects/injury – talk to your doctor about these and then vaccinate your child to protect them and others in your community.
• If your child is one of the unlucky few to suffer from vaccine side effects, let your doctor know and see what options you can explore to protect them and others in your community.
• Some people are anti-vaxxers because they are getting paid to not be well educated in this field.
• Some people are doing the best they can with the knowledge, information and understanding that they have in a society where they feel pressured and judged. They need your support, compassion and empathy to change.
• Always remember, before you get personal, some people’s views are best considered with Hanlon’s razor…..

As far as COVID-19 is concerned……  virology is really not my strong suit, so I am going to keep quiet! Keep washing your hands, stop buying shopping trolleys full of toilet paper and stay well.

Fitness & Health

Az

A review of two misconceptions in social media today.

So, when I am treating school age patients, I love to know what their plans are for the future, what sports they are doing (and to what level) and also what subjects they enjoy at school. Personally, I was a maths and science geek at school (bet you couldn’t have guessed that??), so I often take some of that understanding for granted.

Infographs are quite common on social media and they can provide good information in an easy to understand way. However, like a lot of information available on the internet today, you need to be careful and really check the source and the data before you accept it as wrote!

WARNING: A bit of math and numbers coming up!!

This morning I saw a post in my feed on pistachio nuts and I thought “I wonder if they really are that effective for sleep”, but rather than get caught up in the “Does melatonin work for sleep?” debate, I figured reviewing the data behind the claim would be the best place to start.

Example 1

Credit Dr Vegan

So, here we go. The inforgraph suggests that eating just two pistachios before bed will help with sleep as they are the most melatonin rich food ever recorded and that a handful is like taking a high dose supplement.

Looking at some of the research out there, a report published in Nutrients in 2017 claims that there were 233,000 nanograms of melatonin per gram of dry weight pistachios, substantially higher than most other assessed foods. This really is a large amount of melatonin, and these results do not appear to have been replicated to date.

Interestingly an infograph from the American Pistachio Growers cites the 2017 study but notes that a Louisiana State University analysis (in conjunction with the growers association) showed only 660 nanograms per gram of pistachio was found. It is interesting that they reviewed the 2017 article, clearly had an interest in supporting a finding of high melatonin levels, but only found levels of 660 nanograms/g (less than 0.3% of the 2017 study).

This is where the math comes in again. If we accept the 233,000ng/g finding, then the above info may be correct as therapeutic dosing of melatonin can be as low as 0.3mg (300,000ng), but high dosage supplements (not medications) here in New Zealand sit between 3-10mg (3,000,000-10,000,000ng). This means that 2 nuts at 0.57g each, would exceed the lowest therapeutic amount, but, high doses would require:

mg x 1,000,000 / 233,000 nanograms = number of grams of pistachios / 0.57g (average nut weight)

• 23 nuts for 3mg of melatonin.
• 76 nuts for 10mg of melatonin.

Of course, if the Louisiana State paper is correct, the numbers fly up:

mg x 1,000,000 / 660 nanograms = number of grams of pistachios / 0.57g (average nut weight)

• 7975 nuts for 3mg of melatonin.
• 26582 nuts for 10mg of melatonin.

Given there is no confirmation of the concentration of melatonin in the nuts, with two, somewhat, contrary sources, I think to consider if buying/eating pistachio nuts is a great idea for your health, wealth and happiness (and sleep), it would only be fair that we took the highest reported melatonin level (most supportive of the premise) as wrote/established.

So if we compare costs here in New Zealand – a supermarket brand price for shelled pistachios is $7.00 for 120g, at 23 nuts or 13.11g per dose, you would get 9 doses at a cost of $0.78 each. A 3mg supplement tablet can be bought at $14.49 for 200 at a cost of $0.07 per dose, 1/10 of the cost.

Conclusion

So, are pistachios good for your sleep?

• Possibly but the research is not yet clear on this matter – perhaps you only need to munch on 2-23 nuts per night to sleep like a baby, or perhaps a feast of almost 8000 nuts (4kgs) is required.
• If you are budget conscious and keen to give melatonin a try, the supplements appear a far better bang for your buck at a tenth the price.
• Major take home – personally I like pistachios, so, I might just give them a try, but more likely as they fit well within my current dietary approach and taste good rather than for any thoughts that these might improve my sleep.

Example 2

A number of months back I literally found my self (face to face) arguing with a vegan about where you can get your protein, long chain fatty acids and creatine from, and one of his arguments was the broccoli had higher protein than steak…… (see the infographic below). Now I am NOT a nutritionist or dietician, but I was interested in having a closer look at this claim.

Credit Vegan Street

So, sounds like broccoli is the winner… or is it.

Beyond simply questioning the statistics on the infographic, the joys of having an interest in science and math is understanding units of measure. Calories are a very unusual measure to use when looking at a volume of food. This is because foods have different caloric/energy densities, a concept that even forms part of some diet approaches and medical recommendations.

Before I start trying to put the numbers into an easier to understand and less deceptive format, lets first look at the claimed protein levels. NutritionIX has handy calculators which, once calculated put 100 calories of broccoli at 6.9 grams of protein and steak at 9.4. This is quite a bit different from the amounts noted.

Lets look at this in a different way, to gain the recommended protein intake per day, Healthline recommends 56gm per day for a man and 46gm per day for a woman (average individuals).

Using some mathematics;

Recommended protein / protein per 100 calories * 100 calories = calories of broccoli/steak to be consumed

• A man would need 812 calories of broccoli or 595 calories of steak.
• A woman would need 667 calories of broccoli or 489 calories of steak.

I hope you are with me so far, because this is where things get interesting. Using NutritionIX and some reverse math, 100 calories of; broccoli is 286gms, or 36gms of steak.

This means daily recommended intake becomes:

• 2.32kg of broccoli or 214gms of steak for a man.
• 1.9kg of broccoli or 176gms of steak for a woman.

McCaskie’s butcher (UK) notes that the most common size of a steak is 225gms – so you would be pretty much sorted with one standard steak meal.

Healthline notes that 1 cup of broccoli weights 91gms, so you would need to consume 25.5 cups (male) / 21 cups (female) of broccoli to get the same. Now, if we took the claimed 11.1gms per 100 calories, it would still require consumption of the best part of 16 cups for an average male and 13 cups for the average female. (It is worth noting that a simple google search will demonstrate that the average serving size for broccoli is 1 cup per person per meal.)

Unfortunately, even putting aside concerns about the claims of 11.1gms of protein per 100 calories, consuming anywhere from 13-26 cups of broccoli in a day would not be a good way for anyone to get their daily protein, and it would give you, more than 190%-300% (put in 1456g for 16 cups, 2320g for 25.5) of the recommended daily fibre intake….. so you would be VERY, umm, regular….

Conclusion

Is Broccoli a good source of protein?

• As far as vegetables go…. yes!
• Is it a source of protein comparable to steak? Well, no, not even close.
• Should you try and get your daily protein from broccoli alone? Well, I wouldn’t recommend it, I am sure you have more important uses of your time…… unless you really need to catch up on your social media.

The take homes:

• Infographs on social media can be a great source of information in an easy to digest way, however, be very careful when there are statistics involved.
• It is important that the source of these statistics is noted and if they seem surprising, look into them a bit before you end up believing them to be true.
• Like Pistachios? You could try a couple at night before bed, but it could end up an expensive habit if you want to try high dose melatonin.
• If you are already vegetarian/vegan, broccoli is a great source of protein – but sadly, it simply cannot hold a candle to the might of steak, if you are looking for a primary source of protein in your diet.
• If you are not all that sure if the claims/statistics are true or false, talk to a medical or registered health professional before you try to apply any conclusions to your life.
• Stay sceptical – people love to twist numbers to support what they think.

Health & Fitness

Az

A review of an interesting opinion piece on The Physio Network by Todd Hargrove.

Image of Mike Meyers in The Love Guru. Credit KarryOn

Summary of the article

• Experts are those with an in-depth knowledge of a subject and acceptance that they do not know everything about it.
• Gurus know enough to convince novices that they are in the know, but never mention that they don’t know it all.
• These Gurus don’t have the magic answer to cure all that ails us, and you should view them with suspicion.
• Experts, on the other hand, explain the uncertainty and accept that they don’t know it all (even telling people about this).
• “Maybe we should only call people gurus if they are to blame for their inflated reputations – maybe by inventing false credentials, or preying on the naïveté of the public”?

My perspective

Throughout my career I have been labelled an expert (and even a guru) by patients, but interestingly enough, this was based on what my interaction meant for the patient in front of me – nothing I had direct control over.

I personally take more pride when someone tells me they can see I am doing my best to follow evidence based and best practice treatment when working with them – one of the major reasons I do not support terminology and titles (earned or implied) as a way to identify competence or ability.

Most of us within the clinical space find it frustrating when misinformation is used to sell a particular product, service or approach. And don’t get me wrong, there are plenty of people and services that fall within the stereotypes described in Todd’s blog post, but I feel a little more information and discussion is warranted.

The issues (as I see them)

The issue that I have with a post like this is that it defines “expert” and “guru” as completely different, and with negative connotations artificially lumped on to one of these titles.

It is a bit of a false application of the Dunning-Kruger effect, lumping all of the cognitive bias on Gurus. It is fair to say that simply because you accept that you don’t know everything, does not mean that you accurately appreciate how much you do know.

• “For example, people like Lorimer Moseley, Paul Hodges and Greg Lehman have spent years studying and researching pain and movement, but will frequently remind their audience of how much they don’t know. When asked about how to apply their knowledge to solve a specific problem, they will very often say something like “it depends”, or “I would need to know more” or even “no one really knows!””

To suggest that all guru’s believe that they know everything about a topic and experts accept that they don’t, is a false dichotomy (suggesting that the conclusion must be either A or B when the reality is that there are shades of grey between these options) and this is a significant issue in the consideration of this position. Given the title may be bestowed by the public, and a lot of very humble, very good clinicians would consider themselves neither, it’s really not that clear cut. Splitting the two terms based on an expert’s acceptance and willingness to express that they don’t know it all, is also problematic and viewing it as such may encourage a new marketing ploy for the sellers of “Woo” – self deprecation.

• Will my snake oil cure your cancer, you ask? Why, I would really need to know more, as it depends on many different factors and no one really knows….. but it works for most other conditions with vibra-rotational ionic membrane dysfunction*…..

(*term I made up to make this point.)

This is the issue with reversing the logic on biases – accepting that you don’t know it all does not mean you are not suffering from the Dunning-Kruger effect. Its the same as “All thumbs are fingers – but not all fingers are thumbs”.

Credit: what.thedailywtf.com

When trying to determine the difference between someone who’s opinion, advice or input may have great value, and someone who should be avoided, this dichotomy of expert vs guru sets that bar, not too high or too low, but rather, in a totally different athletic park.

Like most people who understand a science-based approach, I believe that we need to learn how to test out the internal and external validity of opinions, rather than basing our opinion of a concept’s worth, on if the person providing the opinion is an “expert” or a “guru” (or what ever other title they choose to apply – see Master Trainer) – that would be, after all, a sort of reverse argumentum ab auctoritate or argument from authority i.e. we would be seeking the presence of an authority to validate the concept, rather than judging it on its own validity.

I recently read a Facebook post for a Chiropractor that appalled me (review to come), but on reading through the information on his website, I could see how he worked through what he knew and got there. Some of the information was quite correct, but it appeared that he simply struggled to interpret and apply the information correctly – he was noting facts and coming to conclusions (logically, when his bias was considered), trying to express an expert opinion, but failing, not because he had a lack of understanding of how little he knew (Dunning-Kruger), but rather because he drew the bow a bit too far.

• It is correct to say that life jackets save lives at sea, it is not correct to say all people who fall in the sea would be saved by a life jacket.

So, while I think that Todd has the right idea in mind, I have watched many “Experts” become “Gurus” (as per his definitions), including a number of the pain science community, strength & conditioning world and musculoskeletal physiotherapy. I believe that he is well read, I believe that a lot of people are, but critical thinking, understanding where flaws in reasoning happen or when assumptions are presented as findings or facts, is more likely to keep you safe from falling into the next fad diet, treatment or exercise trend than an artificial dichotomous classification of Guru or Expert.

A word to the wise – take care with experts and gurus, as well as people who are any combination of the above. Anyone who is, or views themselves as so specialised as to seek a position as either expert or guru, may have lost the wider view, to consider the whole person or full clinical picture. Just because you accept and/or state that you don’t know it all, does not stop you from selling what you believe is the best information at the time, even if this is not well supported in the literature. Look for a critical thinker, someone who can give you logical advice that makes sense across different fields of understanding and perhaps someone who is not looking to grow a reputation or a following.

I will say this, however, I actually support the first quote I used from Todd above, that actually, the issues come when someone is responsible for their own inflated reputation or where they falsely claim a special knowledge or skill, but we have another word for those people – Charlatans.

Stay sceptical, ask questions, and realise that if it seems to be too good to be true or it applies to everything, it probably is and it probably doesn’t (respectively).

Health & Fitness

Az

Some thoughts on getting a chiropractor involved with your rehab, an old post from FaceBook and how to pick a professional.

As happens from time to time, my clinical load has me thinking about the role of different professionals in the rehabilitation of patients. These last few weeks have been interesting as I have had a number of the chiropractic faithful attend for; second opinions (patient generated due to dissatisfaction), physiotherapy reviews (requested by the treating chiropractor), clinical reviews and full treatment review consultations.

I say the “chiropractic faithful” as, those of the community who find their treatment effective for their musculoskeletal problems, tend to be frightfully faithful to the theology that bones of the spine become subluxated/subluxed (sit slightly out of place) and that the chiropractic adjustment “returns” them to alignment. This concept of Bones Out Of Place (Referred to as BOOP by Jarod Hall – physiotherapist) has not been well supported by research, with even chiropractic clinics confirming that this is not the answer to the “pop” or “crack” that you hear at times when a manipulation is performed.

While a number of science based practitioners out there are solidly “anti-chiropractic”, I must say that my experience at a corporate level, as well as anecdotally within my own clinic and professional sphere, has lead me to believe that there are good and bad chiropractors, in just the same way as there are some terrible doctors (integrative/CAM/functional), physiotherapists and even surgeons (e.g. meniscetomies on 60+ year old knees with osteoarthritis). I would say my experience is that more of them hold to DD Palmer’s original vitalistic approach to chiropractic, than accept the modern clinical sciences explanation for care, but at times I do wonder something similar about my own profession.

Logo for The Good Guys Shops (Australia)

In the last few weeks, however, I had a patient referred by a chiropractor that really felt that their treatment approach was not working and the patient was seeking something more, and a chiropractor providing an exercise based rehabilitation approach focusing on desensitising a patient’s kinesiophobia (fear of movement/activity) and improving their self efficacy. For those that don’t know, these are definitely some of the “good guys”. If you are seeing a chiropractor who is using good evidence based treatment like these guys, your symptoms should be getting better and you should be increasing your independence and self management with decreasing need for passive/hands on treatment.

Credit: Home on the Grange – WordPress

Mean while, I had another client with a 20 year+ history of ongoing “maintenance” treatment with increased frequency when “something went out”.

This sadly reminded me of a post I put on FaceBook in August 2018 which, when I think of it now, was my first social media published review. I had a number of people ask to be able to share the post (I had it locked down pretty tight then), so I thought that this might be a better forum and chance to put this information out there.

The discussion below was following seeing a video of a chiropractor performing a “maintenance” assessment and treatment on a patient with no physical complaints. I have added a few words here and there (underlined) to the original post to make it clearer with the current photos and my improved sense of the English language (just joking).

FaceBook Post August 2018

So I was scrolling through my feed on FaceBook today (dangerous I know) and I saw a colleague had posted a video from a chiropractor. It was about why you should have regular chiropractic input for your wellness.

He performed an assessment getting the client to tuck in her chin, then extend her neck and then he passively bent her knees. He exclaimed that there was a discrepancy in length.

I would like to take the time to point out a couple of issues with this and I have attached a couple of screen shots below to help out.

Issue one – the camera was actually not level (check out the desk in the background in the unedited video capture).

Unedited Video Screen Capture

Issue two – the patient has wonderfully coloured heels on her shoes to really highlight the issue, but look carefully. Her Right foot (on the left side of the photo) is in dorsiflexion/ankle bent so that the toes are closer to the knee (which relatively elevates the heel in this position) and the Left foot (right side of the photo) is in plantar flexion/ankle bent so that the toes are pointed down away from the knee (which relatively drops the heel).

Issue three – Look at the angle of her legs! In the edited video capture I have put a level marker and two arrows so that you can see, her Left leg (on the right) is leaned all the way over to meet with her Right leg. Now you take two equal length sticks, rest them 10cms apart on the ground and lean one over to the other and see if they look the same height….

Edited Video Screen Capture

Issue four – can you see the angle he is looking at the “length” from??

Now here is where things get hard to understand…… this assessment was to see if her neck vertebra were subluxated! Apparently the length of her tibia and fibula, sitting on her femur at the knee are somehow linked to her C1 and C5 resting anatomical positions!

Don’t even get me started on the long lever (two hands on the patient’s head) high velocity rotation manipulations, or the hip in flexion “SIJ” (actually spinal rotation) manipulation that was also included in the video.

How does this exist in a world where we are constantly under pressure to remain “best practise”?

Now I would completely understand the stance of “Different things work for different people Aaron….” and “Does it really matter if the patient gets an outcome from the treatment due to their buy in?” – but this is a maintenance “treatment” on a healthy, “normal” person…..

I’ll get off my soap box now.

August 2018

While we often say “What harm is it really causing?” the issues arise when people who are regularly exposed to this theory believe that there is something structurally “wrong” with them and that this could be harmful to their health. It can lead to feelings of fragility about their spine/neck/lower back, fear of injury, kinesiophobia, and decreased self efficacy which have been shown to impact pain and disability in musculoskeletal pain. I’m not going to touch on the claims of chiropractic for the treatment of medical conditions, anti-vaccination stances or treatment of new born babies here (those issues may be a topic for another day), but I hope that you get the idea that you need to find one of “The Good Guys” as described above.

Earlier this year, I was asked to do some collaborative work for Critical Fitness (a critical thinking and evidence based health & fitness information website) on the levels of evidence based treatment provided by physiotherapists in Australia. Rather than re-invent the wheel and be accused of bias, here is the advice I provided about selecting a good physiotherapist, which is just as applicable to picking a good chiropractor:

How to identify a good Health Professional

The take-home message is to check that your treatment is from recommended guidelines and only supplemented with well-explained alternatives. While you might not know what these guidelines are (it’s not like there is a public list) as a general rule, this should include;

• Education – understandable and positively focused, to ensure that you know exactly what is causing your problem and what you can do about it.
• Goal setting – so that treatment is focused on achieving what is important to you.
• Advice on activities/exercise – guidance towards activities that are positive and helpful to your condition.
• Treatment – aimed at improving your symptoms and independence.

You should only need to seek assessment or treatment if you have an actual problem, maintenance is not generally required, and your health team (medical, clinical and health & fitness professionals) should all be aiming to have you managing your own health in effective ways with good lifestyle choices. If in doubt, get to your doctor and ask for some names of well respected professionals to help you on your way.

Health & Fitness

Az