But…but…it worked for me!

What does apple cider debunking, overpronation and cigarette smoking, Oscon supplements for Severs disease and vaccines causing autism have to do with each other?

^^^ that is the final slide in a video from my Critical Thinking Boot Camp. Anyone who blogs about science always get responses and comments with anecdotes about what was written with responses that it either does or does not apply to them. The science either ‘sucks’ or is the ‘greatest thing since sliced bread’ depending on the anecdote! It has now reached the point where I just delete that anecdotal comments on my posts as they contribute nothing of use to the topic under discussion. Steve Novella succinctly summed this up:

It is almost inevitable that whenever we post an article critical of the claims being made for a particular treatment, alternative philosophy, or alternative profession, someone in the comments will counter a careful examination of published scientific evidence with an anecdote. Their arguments boils down to, “It worked for me, so all of your scientific evidence and plausibility is irrelevant.”

In my other blog, I previously litigated all the issues around “anecdotes” and why useless treatment sometimes appear as though they did work. I don’t intend re-litigating the same issues here but develop them further with some examples I have dealt with recently. For background, I refer you to those two posts.

Health Benefits of Apple Cider
My first example comes from a blog post by Melinda Moyer following an article she wrote on the health benefit of apple cider. These three quotes sum up the issue:

After getting hate mail for debunking the health claims of apple cider vinegar, I’m explaining why I rely on science, not rumors.

Last month, I wrote my first Truth Serum column, “What Apple Cider Vinegar Can—and Can’t—Do for Your Health,” which explored what the science says about apple cider vinegar’s supposed health effects. I found that there isn’t much evidence ACV can cure colds, heal acne, help you lose weight, or alleviate heartburn—and that vinegar can sometimes be harmful.

Then came the angry emails and Facebook posts. Readers chided me for interviewing researchers and doctors rather than people who have actually been helped by apple cider vinegar. Others felt the evidence is irrelevant; vinegar works for them, so they’ll keep using it. A few implied that my writing was unbalanced and unfair.

I am sure you can see the issue …

“The Truth about Overpronation”
I and many others have written about the nonsense surrounding “overpronation” and no point litigating them here … again. To me the evidence is clear. The two most recent systematic reviews/meta-analyses show that it is only a small risk factor, but still statistically significant. I and others are forever dealing with what can only be called ‘clowns’ in social media who cherry pick the studies that show its not a risk factor and ignore those that show it is and then resort to the whole gambit of logical fallacies when called out on it. When the evidence is conflicted like that, you need to defer to what the formal systematic reviews and meta-analyses say (however my next blog post will be on how to bias a systematic review and meta-analysis!).

I only raise this now as a number of times recently I have seen this YouTube video used as “evidence” that “overpronation” is not a problem. Firstly, You Tube videos are not evidence of anything! Secondly, whenever you see “The Truth About…” in the title, there is typically less truth in the actual content. Thirdly, yes that video does show Haille Gebrselassie massively “overpronating”. He was a very good elite runner and almost never got an injury. It is held up as evidence that “overpronation” is not a problem and following on from that, foot orthotics can’t possibly work (Dunning-Kruger in full flight). So who are you going to believe? The anecdote or the preponderance of scientific evidence? I have been in exchanges several times in recent months on this one. What those using the anecdote (But…but…it worked for me!) fail to comprehend is that “overpronation” is a risk factor. It increases your risk or chances of getting a problem. So, of course, there are always going to be an example of people who “overpronate” and don’t get problems. That is NOT evidence. The analogy is that I do not think anyone will disagree that smoking is a risk factor for lung cancer. Just because there are anecdotes of people who smoke their whole lives and do not get lung cancer is NOT evidence that smoking is not a risk factor for lung cancer.

Oscon Supplements for Severs Disease
Another one that came up for was that I wrote elsewhere about Oscon supplements for Severs disease (calcaneal apophysitis). Oscon is a supplement with ingredients that are at their best,  are very very mildly anti-inflammatory. It is marketed specifically for Severs and Osgood-Schlatters, totally supported by testimonials on the website. Not one bit of research has shown that they work and the physiological mechanism that they could work by (very very mild anti-inflammatory) is certainly not specific to Severs and Osgood-Schlatters and there is no way that it could be. ‘Inflammation’ probably occurs in Severs and Osgood-Schlatters, but is not really seen as an important underpinning mechanism and certainly anti-inflammatory drugs are not used, nor recommended for their management. If the supplement “works” for Severs, then it “worked” because of the placebo effect, due to the natural history or anyone of the other seven reasons why ineffective treatments sometimes work. Try telling that to someone who used Oscon in their child and they got better. This was the response I got to what I wrote:

Sadly your report also has nothing to do with talking to people with first hand experience. My daughter is as a gymnast for 10 years, 6 years of which we’re at international level competing for Great Britain. She developed Severs at around 9 years old and it was awful, like watching a little old woman walk about. She had every treatment she could, physio, stretching, anti-inflammatories etc etc, nothing helped for 2 years, she had to ‘manage’ the times with intense pain. Someone in the gym mentioned Oscon and I ordered it, after looking it up on line and discovering it’s general use in the USA and also checking with British Gymnastics it was ‘safe’ from a competition/enhancement perspective. Within 1 WEEK she was 75% better, after 2 weeks it was 85% pain free and I couldn’t believe it. The last 15% was a privately paid for shoe insert made from a mould to support her foot. I told 2 other people about it and. Both had the same reaction for their children. Sadly this appears to be a word-of-mouth cire But there are plenty of discussion online to support what I’m saying. This is your first hand experience you should of had before writing your report

Placebo, natural history, etc. There is a reason that you should never rely on anecdotes. BUT, try telling that to those who have no idea about science, critical thinking and logical fallacies. Can you see the pattern that I am developing in this post?

Vaccines and Autism
Lastly, and clearly, vaccines do not cause autism spectrum disorder (ASD). The evidence is clear and strong. Despite that, the cranks still make stuff up, lie, spout conspiracy theories, refer to retracted, debunked, irrelevant and poorly done studies to support the claims and ignore the strength and the overwhelming number of the well-done studies that show it’s not the case. One of the criticisms of the “science” by the cranks is that they do not take into account the experiences of those parents who children first developed the ASD symptoms following the MMR vaccine….therefore the “science” is wrong (not quite the “But…but…it worked for me!” … but it is still the belief in the anecdote outweighs the science). How much weight should be given to those parents whose child developed autism following the MMR vaccine?

‘Fallacy Man” over at the Logic of Science blog did an awesome job of addressing this (strongly suggest you read it). Using mathematical probably and some modelling based on prevalence data, it looks like that on average 154 children a day in the USA will start showing the signs of ASD (or 1079 a week or 4623 a month). This means that 154 children will start showing the signs of ASD within 24 hrs of getting the MMR vaccine (or 1079 within a week; or 4623 within a month). Now try convincing that parents of those 154 or 1079 or 4623 that it was not the vaccine and would have happened by chance anyway is going to be an exercise in futility. From there, they then fall into the cesspool, conspiracy theories and made up stuff of the antivaccine movement, especially if they have predispositions to those characteristics. What they fail to see is that 154 children will first show the signs of ASD in the 24 hours before they get the MMR vaccine (or 1079 in the week before; or 4623 in the month before).

Surely it is obvious why the science has to outweigh the anecdote to get to the bottom of the problem. In this oversimplified example, the epidemiological research will look if there are statistically significantly more than the 154 children within 24 hrs (or within 1079 a week or within 4623 a month) who develop the symptoms of ASD following the MMR vaccine. That research has been done and there isn’t. What has happened though is the parents of the 154 (or 1079; or 4623) each year become a force to be reckoned with, even though they are misguided. Significant resources have to be diverted to countering the message coming from the cranks in that community. Resources that could be better spent finding the real cause and doing real things that actually do help.

Conclusion:
Hopefully, you can see where the ‘journey’ of this post has taken me. On my other blog, my tagline is “As always: I go where the evidence takes me until convinced otherwise…”. There is a reason for that and what I wrote above is that reason.

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How does stuff like this make it into professional journals?

Any publication with the title of A Novel Treatment Approach to Over-Pronation Dysfunction is going to get my attention, mostly because of the nonsensical understanding of “overpronation”. I was not disappointed and it was as bad as I expected.

Even before I got the full paper, just reading bits like this in the preview: “The literature supports a forefoot varus as the most frequent cause of over-pronation compensation. 1,2“. The two cited references did not show that and one was him quoting himself saying that. The alarm bells start going off about a lack of academic rigour and lack of critical thinking skills. A true forefoot varus (based on the textbook definition) is actually quite rare and far from being a common casue of “overpronation”.

On reviewing the full paper, the author proposes a new treatment for forefoot varus (which he has a patent on), when they don’t even know what forefoot varus really is! The author is confusing the theoretical constructs of ‘forefoot varus’ and ‘forefoot supinatus’ and really has no clue how foot orthotics even work in those two different constructs. There is certainly a lack of critical thinking skills and academic rigour in what is being written by the author (not to mentioned the editorial and peer review processes that allowed it to be published). I have written many times before (eg) about this confusion between the two and the chicken and egg situation with research that is done on one or the other or both.

I went onto great detail on the difference between the theoretical constructs of forefoot varus and forefoot supinatus here. Both present as an inverted forefoot when the lateral column is loaded and the rearfoot about neutral. Basically, the construct of forefoot varus is that it is osseous, rare, not correctable and is a cause of “overpronation”; whereas the construct of forefoot supinatus is that it is a soft tissue contracture, common, is correctable, but is the result of “overpronation”.

A simple cursory read of the paper shows that the author had no idea about forefoot supinatus (and does not even mention it) and ascribes some of the characteristics of forefoot supinatus to confuse it with what he thinks is a forefoot varus (its not). As a forefoot supinatus is a soft tissue contracture, then what he proposes can be helpful, is not new and is not novel and has been like a number of strategies that have been used for a forefoot supinatus over the years. The nature of what he is proposing will facilitate the stretching out of the soft tissue contracture as have mobilisation techniques been doing that for years. So too has the nature of the short foot exercise been restoring the “arch height” of those with a forefoot supinatus. However, all those techniques, including the one proposed by the author, will fail in a forefoot varus as it is a bony or osseous issue.

The problem with a forefoot supinatus is something is causing it. This is not acknowledged by the author, let alone understood by him. The approach advocated by the author is destined to fail in the long term unless that cause is removed. Short terms gains in arch height could be expected with what he is proposing.

The author then justifies his approach by applying the “it worked for me” logical fallacy. Seriously? In a professional journal?

At least the journal did include a response by Robert D. Phillips, DPM to what was published. My only criticism of what Daryl wrote is that he was too polite and should have ridiculed the concept.

I do acknowledge that there can be a difference of professional opinions, but in this case, this is not a case of professional opinion, but a confused superfical misunderstanding of the literature and a misunderstanding and misuse of concepts and terminology. It certainly lacks the academic rigour to be published in a professional journal.

On one hand, I am perplexed how something as confused as this can make it through the editorial and peer review process of a professional journal. On the other hand, we are talking about JAPMA who regularly publishes papers that are below an acceptable standard (see my posts here and here) and for some reason, republished the paper that was previously published in another journal (Journal of Orthopaedic Physical Therapy Practice) that from what I can tell does not even exist as a journal. There is a magazine by that name, but not a journal!

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