The ABT dilemma: Testing the limits of evidence-based practice, or undermining it?

A thought experiment is a useful way to get to essence of an argument, dilemma or pickle.

I am excited to announce a new therapeutic modality called ABT(Trademarked).  I’ve developed it over a number of years and had great success in reducing pain and disability in clients with chronic musculoskeletal pain.

ABT(TM) is a client-centred approach that is based on emerging understandings of the fascial system and adheres to the principles of coaxial quasi-chaotic biotensegrity.  The hands-on method works through the skin and gently locates and modulates three-dimensional force transmission to alleviate symptoms by depolarising the ionic potential of subcutaneous nerve receptors and reducing intra-cellular disruption.  This also has been shown to up-regulate the uptake of norepinephrine by the recently discovered area of the brain called Shatner’s bassoon – located posterior to the ventromedial prefrontal cortex and explains why this has such profound effects in improving wellbeing.

I run courses for therapists to gain ABT(TM) qualification.  These are expensive but very high-quality.  I also run advanced top-up courses that should be taken every two years to ensure the highest quality skill development and offer routes to master practitioner status.  The course is attended by physios, osteopaths and massage therapists alike who really want to see better results for the clients who have found their current skills limited and often ineffective.  Our growing online community provides great peer support, and we are a truly multidisciplinary family.  ABT(TM) T-shirts are supplied to all course graduates.  ABT(TM) has a huge social media following and thousands of positive testimonials from satisfied students and clients.

Now here’s the twist, ABT(TM) stands for Absolute Bullshit Therapy – I made it up.  It is biologically implausible and has absolutely no supporting evidence, a fantasy.  Yet somehow the language looks familiar, and it’s enticing.  I really enjoyed writing it and was tempted to embellish further with tales of the ancients who knew all this thousands of years ago and only now explained by quantum something-or-other, then layer on some quasi-conspiratorial guff about how pharma wants to suppress these secrets, so click my link quickly before they take it down, black Friday bargains aplenty for the swift clickers.

So what happens now?  You take the ABT(TM) course and you’re off. 5-10 years later after the method has gained popularity from good marketing and then comes some real research.  A group of researchers interested in exploring the efficacy of the method run a series of experiments and compare it with a placebo, with no treatment and with sham-ABT and guess what?  No significant differences, no clinically meaningful effect sizes, no better than placebo.  It doesn’t work, despite the angry protestations of the ABT(TM) therapists who just know it works!  A few more years go by, more studies, and systematic reviews with meta-analysis show small, non-significant effects and question the mechanisms that underlie the method as ‘not rooted in physiology or reflecting contemporaneous research into pain’.  But the objections come in, “I’ve been doing this for 10 years, it’s helped so many clients get better when they tried everything else, you can keep your science!!”.  And the drumbeat goes on. Believe me, you see this every day, lotta anger out there in therapy world.

Now it gets really weird.  An emerging idea whispers through the healthcare community, it takes form, its name is biopsychosocial.  Those committed to evidence-based practice like the sound of this, it just feels right.  Now, comes the inevitable claim…

“We know that ABT probably doesn’t do what the originators (still me) claimed it does.  But we also know that clients like it and find it a pleasant experience.  Therefore, it is likely that the empathy and kindness shown by the attentive practitioner serves to de-threaten the experience of pain, and that touch is providing novel sensations that probably elicit descending noxious inhibitory control, reducing pain.”

— The ABT practitioner community

We’ve heard all these arguments before. Here then, is the problem, an actual de facto bullshit therapy is argued about in a community of health professional as potentially justifiable.  Can this really be reconciled with the intention of evidence-based practice?  While the steps in reasoning can sound appealing, if you’re including a pseudoscientific therapy into evidence-based practice, then you need to explain to me very carefully what you think evidence-based practice is.

Perhaps our professional credibility is at stake here. Are we better off distancing ourselves from ABT? Is it enough to update the narrative around ABT, or should we let it go? Or to think of it another way, would we want ABT to be used 50 years from now?

The thought experiment is intended to separate out the debates about the efficacy of a therapy from where do we draw the line in what is acceptable in principle. The two are often debated together and fail to get to the essence of the pickle.

Thanks for making it to here,

Tris

Limited supply of ABT hoodies available this winter, so hurry.