The Death of Moderation

Yes, the title is fairly paradoxical, but what the hell happened to moderate health messages?

So I am kicking off a new instalment of this blog – Critical Health – with a fairly inflammatory statement about inflammatory statements.. Ironic!? Well, you just wait for the rest of the blog. Has the human predilection for dichotomous thinking gone too far in the social media age?

Sugar or meat? Meat or vegan? Sleep or everything else? Manual therapy or exercise? Surgery or no surgery?

As a physiotherapist, I will stick to topics I am most equipped to comment on, but I cannot sit idly by and write a blog about polarising health messages without getting into diet. Just make sure you fact-check the diet conversation. What follows is MY TAKE on debates (yes, I know, by nature dichotomous, but it doesn’t mean the answer is one or the other in ‘real-life’!) that rage within the current climate, which I have most trouble with. If you have some of your own, please let us know!

The pendulum will always swing, and by in-large, whilst an argument rages it will have to be pushed forwards by two opposing and extreme view-points until it eventually settles somewhere in the middle. BUT in the age of Instagram, Facebook and Twitter, these arguments are played out on a world-stage and the uneducated followers are misinformed and misguided, being lead to believe the answer lays at one ‘pole’ or the other. All the while particular camps’ viewpoints are being monetised and ingrained into public opinion.

Just because you only have 140 characters (now 280), doesn’t mean you have to peddle a completely unconsidered opinion. And as a staunch moderate, the lack of consideration, finer details and nuanced viewpoints in today’s arguments really grinds my gears.

Manual therapy versus exercise?

One of the most polarising debates out there in the physiotherapy specific sphere. Is the time spent on manual therapy completely unfruitful, detrimental and of no value in the treatment paradigm? Should physiotherapist identify as a profession who place little to no value on manual therapy?

I’ve written about this previously, and my views are well summarised by the phrase; do we need to identify as either a ‘manual therapist’ or a ‘physiotherapist who uses exercise’? If both are used in conjunction, and therapists wield the two approaches with skill and restrain, then this can surely enable a ‘complete’ practitioner. A practitioner who is capable of managing expectations and then able to provide the empowering, active approach that will ultimately ensure that patient changes their behaviour. Situations wherein manual therapy will actually be detrimental to improvement are easier to imagine for the clinicians, but I’m sure you can think of alternate situations where exercise therapy isn’t appropriate either. Are manual therapy and exercise therapy mutually exclusive in physiotherapy? No, and I don’t think most physiotherapists actually practice this way. But what’s more, I don’t think that it is beneficial to push a extreme view on this one.

Yes, manual therapy is a treatment with a lower proposed physiological effect over a long term, but it actually has good efficacy in short term pain relief and a lot of landmark Cochrane Reviews include some fairly old and low quality studies.  Similarly, if exercise is wielded in a fashion that does not promote self management and reinforces the reactive, curative paradigm, then surely this is just as inappropriate. I don’t know if it’s manual therapy that we should be blaming, instead the paradigm that goes along with it; one that is based on a reward system for being in pain and the monetisation of a public health burden.

How about we all just identify as ‘physiotherapists’ with a well-rounded skill-set.

Surgery versus no surgery?

There is a mounting evidence base to demonstrate sham surgery is as effective as real surgery; among a few are positive outcomes in meniscal tears, discogenic back pain and SLAP lesions that doing nothing but opening the skin and closing again can be as effective as removing or repairing the proposed pathoanatomical abnormality in the first place. This has spurred on a fairly vocal camp of supporters against any surgical intervention. There are, however, certainly some conditions, where the evidence points to surgery being successful; shoulder osteoarthritis is one, but knee ostoarthritis does not seem to be in the same catgeory.

In defence of surgery for the above conditions, there can be a lot of indications for a patient benefitting from surgery over conservative care. There may be some harm to be caused if surgery is delayed in certain cases, and although the debate about the overall utility of surgery in homogenous conditions is very healthy, painting everyone with the same brush isn’t healthy. Nuance.. what is needed is nuance.

Meat or vegan?

Being a dietitian would be a rough gig. These particular dogmatic, bi-partisan debates seem to be very much more commonplace in dietetics than other allied health fields. One of my personal favourites; should you cut out all meat and animal products or blindly consume all manner of animal products to the detriment of your health and the environment? Now I have no doubt that current practices and market forces in livestock farming have been horrendous for the environment. You can’t deny statistics like 36% of the world’s crop land being used for animal feed NOT human food, and this proportion sky rockets in developed nations – see here. And over 15,000 of the world’s scientists have officially issued a strong warning that if these farming and diet practices continue, we will be headed for environmental catastrophe. The WHO endorsement of red meat causing cancer was an almighty media storm in 2015, and rightly so, this link has been pretty well established in the research for years. Not to mention there are a myriad of reasons that the vegan diet is adopted on ethical, moral, psychological and somatic bases.

But, I just don’t understand why a diet reduced in meat and other animal products, world-over, in other words a plant-based diet is not the logical choice for everyone? We still get our protein, and when consumed only on a seldom basis it would be appreciated more and much higher quality. I’m heavily influenced by Michael Pollan in this argument, I think you should be too. For more information, watch ‘In Defence Of Food’ on Netflix.. Yes, my first big of 2018 includes a reference to Netflix.

Well there you have it, the first in more bite-sized blogs. I wanted to dissect more arguments, but there’s plenty of time to get into that. So, to conclude, the moderate message is an important one – tending to be the place where the ‘pendulum’ will land – but unfortunately is getting harder and harder to find nowadays. Let’s bring the moderate message back into the limelight, 280 characters on moderation and nuance – go!

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