Guest post by Rosi Sexton: Why ‘why’ matters

A few days ago, I published this post about the pseudoscience I see frequently in MMA communities. For a different perspective, I invited former professional fighter, osteopath, and all around brilliant person Rosi Sexton to share her thoughts with us. While her position is a bit ‘softer’ than mine, I think it’s important to get a diversity of perspectives, particularly from people who are actually treating patients. Enjoy! –Jennifer

Cupping seems to be the new therapy buzzword around these Olympics. I’ve had a few discussions with people asking me what I think about all these athletes sporting cupping marks on their backs and shoulders. My answer? “Well, that depends”.

Let’s get a few things straight before I go any further. In common with most of the skeptics who have already commented on this latest trend, I think it’s very unlikely that cupping has much of a direct physiological effect. There’s no evidence to suggest that it affects the underlying tissues very much at all, never mind in a way that’s likely to be performance enhancing.

So case closed? Cupping is nonsense, as with so many other ‘trendy’ interventions.

Not so fast. In the absence of claims made for specific physical outcomes, cupping is just a physical activity. It makes no more sense to say that “cupping is nonsense”, any more than it makes sense to say that Morris dancing is nonsense: both activities seem a little odd to me, but if there are people who enjoy them for their own sake, then I’m not about to argue with their experience. Although I’ve never had a cupping treatment, several friends tell me they find it nice and relaxing.

“But where’s the evidence for that?” the skeptics ask; and here’s where I think the problem lies. Sometimes we fail to distinguish adequately between objective claims about fact (“this treatment will make your muscles stronger”) and subjective claims about personal experience (“I had this treatment, and it made me feel really good”). When we start to imply that people’s individual experience is invalid, or wrong, because they don’t have scientific evidence to support it – that’s when sportspeople start to complain that the scientists are arrogant, out of touch curmudgeonly killjoys.

Imagine that someone has conducted a large survey about leisure activities. Suppose the results come back, and it turns out that on average people find quiet country walks and loud, alcohol fuelled parties equally enjoyable. Does this mean that you that your introverted great aunt Agatha will be persuaded to forgo her gentle Sunday afternoon stroll in favour of accompanying you to a nightclub? Unlikely. Telling her there’s evidence that the two activities are equally enjoyable probably wouldn’t be persuasive – because enjoyment is subjective, and Aunt Agatha knows what she likes. The fact that things like pain, discomfort, pleasure and happiness are all subjective and difficult to measure isn’t a reason not to research them – but it does raise difficulties that should be taken into account. I have misgivings about measuring something as complicated as pain on a 1-10 scale, for example; but we have to start somewhere. It also means that we should be very clear about what the research does, and doesn’t, say when we apply it to individuals.

It’s not quite that simple, of course. Perhaps that athlete finds the treatment pleasant and relaxing because he’s been told it’ll have beneficial effects on his performance, when in fact this is highly questionable. The ethics of using placebo effects in top level sport – where winning and losing can be measured in milliseconds – is a subject that needs a whole separate post, but that’s not what I’m advocating here. I think it’s possible to be clear and honest about what’s known about a treatment, and to allow for a person’s individual subjective experience at the same time.

Talking openly with the athlete about why they are using a particular treatment, and being very clear about what they expect it to achieve is an important part of that process. If an athlete I’m treating tells me that she wants to use a treatment like cupping, then my first question is to ask why she’s doing it. I want her to think about what she’s likely to get out of it, and to ensure that it’s not being used instead of evidence based treatment to address any underlying problems. If it’s only giving some temporary relief, could the time and money might be better spent elsewhere? What are the risks of adverse effects, and are the benefits worth it?

As a clinician, I find that framing the conversation in this way to be a more effective way of communicating with my athletes. By taking a hard line against misleading claims but not against the practice itself (except where it’s likely to be actually harmful), it encourages the athlete to apply their own critical thinking. We talk about how athletes can monitor their own experience more methodically, to see whether particular changes to their plan have a consistent (subjective) effect or not.

Learning how to sensibly navigate the large gaps between our small islands of knowledge is something that those in high level sport constantly struggle with. No athlete can afford to use only methods that have been proven rigorously by science – despite the best efforts of sports science there is simply too little evidence out there. At the same time, it’s easy to get suckered in by the latest trendy therapy or product; when winning and losing come down to tiny margins, many athletes feel that they can’t afford to take the risk of not using something just in case it does make a difference. Applying a sceptical thought process while at the same time allowing for personal experience and individual circumstances gives a framework for evaluating these unknowns, whether it’s a “wacky” therapy like cupping, a new training method or a cortisone injection.

Two questions you should never be afraid to ask:

“What, exactly, is this supposed to achieve?”

“What reason do I have to think it can do that?”

I’ve never experienced cupping, but I did have a hot stone massage once. It was lovely. It didn’t cure my neck pain, of course (nor was I expecting it to) – but it was a very pleasant distraction from it for an hour or so. Your mileage may vary.

20 thoughts on “Guest post by Rosi Sexton: Why ‘why’ matters

  1. gewisn August 12, 2016 / 11:47 am

    I call shenanigans!
    Specifically, I call “strawman argument” shenanigans.

    You are portraying the scientific and/or skeptical complaints against cupping as if they are even partly worried about whether there is solid evidence that it feels good. That is a “strawman argument” in that it intentionally misrepresents the argument or stance into a form which you find easier to criticize.

    The primary skeptic complaint about cupping is that the practice is used, touted, and reported in media outlets as having physical performance benefits and that this claim is based on rational physiological understanding, when, in fact, the physiology does not support such a claim and no solid evidence to separate the technique from placebo is available. I know you don’t disagree with the skeptical complaint in that form, so I won’d belabor it.

    Rant Alert!
    Proceed with the caution that the following may cause steam to propel from your ears. :-p

    The other sort of strawman argument used in this article is that the complaint against skeptics is primarily that they are discounting people’s personal experiences. That is simply not the case.
    The vast majority of skeptics are asking where is the evidence that the cupping technique itself (as opposed to the personal attention or the massage aspects or something else involved) is positively affecting the performance, especially when the noticeable bruising is known to be a result of capillary damage, a demonstrable (though minor) obvious harm.

    That is a very different thing than the complaint that skeptics are demanding objective measurement of the enjoyment of an activity before they will accept that individuals did actually enjoy the activity – which is your claim when you write, “several friends tell me they find it nice and relaxing.
    “But where’s the evidence for that?” the skeptics ask; and here’s where I think the problem lies.”

    No. I have never seen a significant skeptic publication suggesting that people don’t enjoy the taste of lobster or don’t enjoy a hot stone massage or don’t enjoy body modification unless there is a double-blind randomized control trial demonstrating such enjoyment with a p-value < 0.1.
    Have you, Dr Sexton? Can you point us to several skeptic publications claiming that people don’t enjoy a particular activity unless that enjoyment can be demonstrated with scientific objective placebo-controlled data?

    Skeptics, by and large, are not concerned with proving that people do or don’t enjoy something. But they are concerned when the enjoyment is used as evidence of other outcomes that are not in evidence. And they also get itchy when people claim that “I feel it helps me,” and that claim itself if considered proof enough to recommend the activity to others as likely to be of help. This problem of, “I feel it’s true, so I’m going to tell you that it is true and that it will be true for you,” extends from quack medical treatments to nutrition to child discipline to hauntings to investment strategies.

    The world is not better off when such thinking is not only common, but it is applauded. People who are encouraged, applauded and rewarded for such thinking are going to be making decisions about you and for you, through voting and business practices and child rearing of your neighbors’ kids and school board policies and federal legislation.

    Incorrectly portraying the skeptical stance as “I don’t think you did enjoy that unless you can provide objective reliable data that you enjoyed it,” is disingenuous and it is not helping you remove that sort of thinking from the world around you.

    Is the sort of thinking that goes into claiming that cupping is “reported to be” (as NBC commentators were told to say) helping elite athletes’ performance, regardless of the lack of evidence, the sort of thinking you want going on in your child’s school board or at the stock exchange or in Congress?

    If not, then you want skeptics challenging such thinking.

    • Rosi Sexton August 12, 2016 / 4:42 pm

      I think I’ve covered most of your points in my other replies below, but just wanted to add…

      ‘And they also get itchy when people claim that “I feel it helps me,” and that claim itself if considered proof enough to recommend the activity to others as likely to be of help’.

      YES! Absolutely. Do you have any idea how twitchy I get about all the bad Facebook medical advice I see? “My knee hurts, what should I do?” “Oh, that sounds like my cartilage tear; you should drink more protein shakes, that’ll sort it”. Aaaaargh!

      It’s not a uniquely alt-med problem – more an unqualified people offering advice problem. But many alt-med practitioners feed off it, it’s true.

      • gewisn August 12, 2016 / 5:37 pm

        I don’t think most of the people following violentmetaphors are missing the fact that you join us in calling out baseless therapies as hogwash, and we didn’t misunderstand that you are agreeing with Dr Raff’s overall points.

        That isn’t the problem I find with the post, Dr Sexton.
        My problems with the post have to do with the incorrect portrayal about the reason alt-med practitioners and users dislike skeptics. You portrayed their reason as being that skeptics demand evidence of their enjoyment, their subjective experience.
        A) Skeptics don’t do that, that I’ve ever seen. They object to using that subjective experience as evidence of objective, physiological improvements.
        B) alt-med users and practitioners don’t complain that skeptics demand evidence of their enjoyment, their subjective experience. They complain that skeptics should accept anecdote and “it’s true for me” as evidence that their favorite alt-med techniques provide objective, physiologic improvement.
        C) Any list I make must have at least 3 items. IT MUST! :-p

        If I missed where you addressed those objections in your other replies, I apologize and I ask you to point me to where you addressed them. Of course, it’s your post and I don’t presume you’re required to ever address my comments.
        🙂

        • Anonymous August 13, 2016 / 3:01 am

          I agree that there are plenty of other reasons why dubious alt-med practitioners and their more hard-core clients dislike skeptics. Some people don’t like having dubious claims pointed out, and yes – these people frustrate me as much as anyone else.

          I’m speaking more of the “casual users” of therapies like cupping – those without a personal investment in the nonsense. They’re the ones who can be educated with the right approach. I see a lot of people who fall into this category.

          Apologies if I gave the impression that everyone does, though – that’s clearly not the case as you rightly point out.

          And I have seen cases where skeptics have criticised people for using a therapy “because I find it reduces my pain”. Pain is a subjective experience, like enjoyment – and pointing to a study that shows that people on average get no significant benefit is unlikely to be persuasive if it runs contrary to someone’s personal experience.

          • Rosi Sexton August 14, 2016 / 3:22 am

            Oops – that was me! Not sure why it posted as Anonymous!

  2. David Colquhoun August 12, 2016 / 12:08 pm

    Thanks for filling in some details of your argument. You probably won’t be surprised that I don’t agree with it entirely.

    I don’t know of anyone who wants to ban even the most absurd of all alt med, homeopathy. All that’s asked is that they don’t make claims that are unjustified. (of course if they actually did that, business would probably decline quite rapidly). It’s quite common for people selling alt med to claim almost anything, right up to curing cancer. You can buy “homeopathic meningitis vaccine” from a company with two Royal Warrants. That’s culpable homicide in my view, and should be condemned unequivocally.

    Of course cupping, if not overdone, doesn’t do much harm, so let’s stick to harmless alt. med. The main thing that sucking up skin is likely to do is suck your wallet dry. That’s not a problem if you are as rich as Phelps and Paltrow. But most athletes are not rich. I found Jennifer’s statement, in her post to which you are responding to be spot on.

    “If I sound angry here, it’s because I am. I see these quacks taking large fees from vulnerable fighters who can’t afford them…. but are convinced that they can’t afford not to pursue any possible advantage. I’ve seen creepy alt med sponsors lurking around events and attaching themselves to athletes as if they were coaches.”

    I would have expected you, given your experience, to be sympathetic to that point of view.

    And there’s another thing that your account omits to mention. Each time an ineffective treatment is tolerated. there is considerable public expense, in the form of colleges that teach things that are known not to be true, in the setting up of “regulatory” bodies that are populated by true believers and act more like advertising agents than regulators. Not to mention the Professional Standards Authority that does more harm than good. A good example is chiropractic which has a “regulator”, the General Chiropractic Council which has the same status as the General Medical Council. This was done by John Major’s government which was evidently unaware of the non-existence of subluxations and “innate energy”. That was in the 90s, but quite recently the Privy Council was deceived into awarding them a royal charter! And still more recently, the minister for universities has given a private chiropractic college the power to award its own “degrees”. I imagine that this was done on ideological grounds (all privatisation is good) rather than because Jo Johnson has any knowledge at all about chiropractic. Nevertheless it gives an air of respectability -as though the government endorses chiropractic.

    I agree with you that the attitude one takes depends on whom one is talking to. I try to avoid discussing alt med with practitioners, or with enthusiasts for it. Experience has shown that no amount of evidence will ever convince them. They want to believe in magic, and no amount of reason will deter them. It’s much more helpful to target government officials and the vice-chancellors of universities that run courses in nonsense. For them, the gloves are off. Polite letters have zero effect. Revealing the nonsense and public shaming can be quite effective.

    So, by all means, use hot stones if you find you like it. But unless you take a strong line about palpable nonsense (like subluxations) you end up appearing to encourage health fraud. That is not good for the public, and it’s not good for physiotherapists and osteopaths who try their best to use such evidence is available. You are clearly on of the latter, so in the end I believe excessive tolerance is not good for you.

  3. Rosi Sexton August 12, 2016 / 3:13 pm

    Let me clarify: I’m not making a case against skeptic arguments in general. In fact, I agree with most of them. If someone is making clearly false claims then I’ll be as quick to criticise those claims as the rest of you. I am ONLY pointing out that if someone’s sole reason for using a therapy is based in their subjective experience, then that may be valid on its own terms. That’s all.

    • David Colquhoun August 12, 2016 / 3:42 pm

      Sure, My response was also “yes, and…”. My main point is that I’ve never met a skeptic who objected to people doing things they enjoy.,as long as they pay for them themselves Their criticism is aimed at the providers and at politicians who support them, not against the customers.

      • Rosi Sexton August 12, 2016 / 4:18 pm

        “Never met a skeptic who objected to people doing things they enjoy”

        This may be true; but let’s remember that things like pain and discomfort are also subjective experiences, like enjoyment. I’ve seen plenty of skeptical criticism of people for using unproven treatments that they claim in their experience reduce their pain.

        What’s more, I’ve seen plenty of criticism of the “gullible” Olympic athletes sporting cupping marks, without having spoken to the athletes or their therapists to ascertain their reason for using it.

        I think our disagreement here is relatively minor, and perhaps stems from our differing perspectives. I’m speaking as a clinician working with individuals who come to me with a range of different experiences and beliefs – my priority here is to communicate with them honestly and helpfully to achieve a positive outcome. (I can honestly say that I lose sleep about this stuff at times, wondering whether I’m getting the right message across.) As someone who is a spokesperson for skeptical and rational thought, used to debating these issues on a public stage, it makes sense that you’d frame your message a bit differently.

        Nonetheless, I think we’re entirely in agreement about fraudulent health claims and dubious alt-med business practices.

        • David Colquhoun August 12, 2016 / 5:13 pm

          I think that we agree on almost everything.

          You do have a point about criticism of the customers. I just said that I don’t go for the customers, but you are quite right that a lot of people, including me, have called them Phelps and Paltrow as gullible. I’ve been rumbled.

          Nevertheless it’s true that customers are not the main butt of criticism for me, certainly not customers who come to you with intractable pain. I suppose that the rich celebrities are so famous that they, inadvertently or otherwise, act as salesmen for the things that they use. In fact their fame is the only reason that cupping is getting into the media at all. They are very atypical customers and because of their fame, they also have responsibility to make sure that what you advocate in public is reasonable. The fact that they don’t is why they get some criticism. For similar reasons, “celebrities” who preach against vaccination should not be immune from criticism.

          • Anonymous August 13, 2016 / 3:06 am

            I absolutely agree that if famous people are advocating dubious practices to anyone else they should be subject to the same criticism (especially with things like anti-vaccination). My only issue is where they’ve not said anything, but their apparent use of a therapy (the visible cupping marks, for example) is read as an endorsement. Of course, people draw all kinds of conclusions merely from the fact that a well known athlete is using something, but that’s not really their fault (and I don’t think their job extends to worrying about that) – that needs to be addressed by better education of the public, as we’re all trying to do (in our own ways). 🙂

            • Rosi Sexton August 14, 2016 / 3:22 am

              (That was me – not sure why it posted as Anonymous!)

  4. Rosi Sexton August 12, 2016 / 3:23 pm

    This post was intended as a reply to Jennifer’s excellent blog on the subject (the majority of which I completely agree with). It should be read as a “yes, and…” rather than a disagreement.

  5. minnavanderpfaltz August 13, 2016 / 4:59 pm

    The “under” implication here is that if it isn’t Western medicine, it’s hocum. You are, thank goodness, offering up an opinion. Where’s your research? Moxa is around 2500 yrs old. Hell of alot safer than steroids–though many athletes use ’em, the kind that disappear in your blood stream by the time of testing! If it works for him and any other athlete, that’s the end of the story. If y’all want to talk about pseudoscience, let’s talk about sports superstitions or much of what Big PHRMA sells us. Or ECT.

    • Chris August 13, 2016 / 9:13 pm

      “Western medicine”

      Where is the meridian that separates “western” from “eastern” medicine? Where does homeopathy stand since it was invented in Germany? Are colonoscopies, statins, varicella vaccine and DTaP vaccines okay dokay “eastern medicine” because they were developed in Japan.

      Denoting practices as “eastern” or “western” has a bit of a racist tone about it. You seem to stereotyping entire populations based on which part of the world they live in.

      “Moxa is around 2500 yrs old.”

      So is bloodletting and trepanning. That statement is just an appeal to antiquity.

  6. David Colquhoun August 13, 2016 / 6:39 pm

    MINNAVANDERPFALTZ

    Perhaps it’s you who should do some research. You seem to be unaware of the real history. I’ll quote from a recent paper, which you can find at
    http://www.dcscience.net/2013/05/30/acupuncture-is-a-theatrical-placebo-the-end-of-a-myth/

    “For almost 1000 years acupuncture was in decline and in 1822 Emperor Dao Guang issued an imperial edict stating that acupuncture and moxibustion should be banned forever from the Imperial Medical Academy.” It continued as a fringe activity

    Acupuncture continued as a minor fringe activity in the 1950s. After the Chinese Civil War, the Chinese Communist Party ridiculed traditional Chinese medicine, including acupuncture, as superstitious. Chairman Mao Zedong later revived traditional Chinese Medicine as part of the Great Proletarian Cultural Revolution of 1966 (Atwood, 2009). The revival was a convenient response to the dearth of medically-trained people in post-war China, and a useful way to increase Chinese nationalism. It is said that Chairman Mao himself preferred Western medicine. His personal physician quotes him as saying “Even though I believe we should promote Chinese medicine, I personally do not believe in it. I don’t take Chinese medicine” Li {Zhisui Li. Private Life Of Chairman Mao: Random House, 1996}.”

    It isn’t a matter of east vs west. It’s a case of no-evidence versus evidence.
    The sort of Chinese medicine which is now sold is not a product of ancient wisdom, but rather, a product of Mao Zedong.

    We can agree about one thing. Moxa is indeed a lot safer than steroids. But that’s not surprising because moxa is a (fairly) harmless placebo whereas steroids actually do something and are indeed dangerous.

    China has a lot of good scientists, but I fear that you must be an embarrassment to them.

  7. Mark Gallagher August 20, 2016 / 5:11 pm

    Thanks for this post, Jenn and/or Rossi. It is a very useful distinction to differentiate between the claims about the value or adverse effects of a practice and the practice itself.

  8. I Am A Science Lady October 21, 2016 / 4:13 pm

    Your post identifies something that I feel is often forgotten in skeptical conversations: that subjective experiences are constructed of emotions. No matter how good the facts are, it’s very difficult to break through that emotional cloak – which is why scientists and skeptics are often seen as cold and not really understanding those who use alternative therapies. This problem isn’t to do with arguing against the practitioners of such therapies, but convincing the unwary consumer that they have no value.

    Is it better to accept that some people we interact with will indulge in woo, and need to figure things out for themselves; or should we exercise a zero-tolerance stance? I suppose it depends on how big an audience we want to reach.

    Thanks for this great post; it has certainly generated some interesting discussions!

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