Pascal’s therapy wager

November 3, 2010

Pascal’s wager refers to a theory put forth by Blaise Pascal, a seventeenth century french philosopher.  It suggests that you might as well believe in God, because belief won’t do you any harm, while non-belief could lead to damnation.  This was his solution to the uncertainty of religion, the fact that you cannot prove beyond a doubt that God exists.

Pascal’s wager has many flaws (for example–which God should you believe in?) and it seems like a kind of overly practical and academic approach to something as weighty as religious faith.  But I think this kind of wager is the way people tend to make decisions–you given up trying to be completely sure and just go with the answer that seems most likely to pay off.   As understandable as this is, it doesn’t seem like the right way to make decisions about things like healthcare, but unfortunately, there is often no other choice.

Take physical therapy for kids with CP.  Like God, it has lots of believers and its importance is touted all over the internet:  “Physical therapy is one of the most important aspects of cerebral palsy therapy” (from Origins of Cerebral Palsy) and “One of the mainstay therapies for cerebral palsy treatment is physical therapy” (from Cerebral Palsy Source).

Also like God, these statements are unproven.  Now I’m not talking about physical therapy in general, just when it comes to people with cerebral palsy.  In a 2008 review of studies of the effects of PT on CP, the researchers “found no strong evidence on the reviewed interventions.”  What they found was that most of the studies were flawed.  Only 4 of the 22 trials were considered “high quality,” and only one of these studied conventional, comprehensive physical therapy.  This physical therapy study concluded that “intensive physiotherapy produced a slightly greater effect than conventional physiotherapy but the factor more strongly associated with increased motor skill acquisition was the use of specific measurable goals.”  In other words, giving children clear goals was more effective than giving them more therapy.

The effectiveness of physical therapy should be easier to test than the existence of God, but it’s actually surprisingly difficult.  For one thing, CP manifests differently in every individual, and even two children with the same diagnosis (spastic quadriplegia, for example) can have two very different sets of skills and challenges.  Physical therapists also differ in quality and approach to treatment, so there is no such thing as a homogeneous group of kids getting the same therapy.

Also, there are no real control groups in studies of physical therapy, because pretty much every kid is getting therapy of some kind.  Many studies compare one kind of therapy to another kind, or regular amounts of therapy to intensive amounts of therapy.  In addition to this,  most kids who take part in these studies keep attending their regular therapy sessions, and often get extra interventions from their parents at home.  Even though physical therapy has not been proven to work for kids with CP, no one wants to give it up for the sake of a study.  That would mean being on the wrong side of the wager.

But are the two sides so clear-cut?  Pascal’s wager is based on the idea that belief is, at worst, benign.  But is physical therapy benign?  In a 1988 study, children who received more therapy made less physical and mental progress and were less likely to walk.  Of course, this is just one study, and it’s very old.  But again, the lack of information is part of the problem.

PT has other, more obvious drawbacks.  For example, children who receive PT at school are pulled from their regular classes and end up missing out on academics, and at home, kids with CP have “therapy moms” who shuttle equipment-loaded SUVs from clinic to clinic, stuffing hours of therapy into their weeks.

People are beginning to question the overly structured schedules of kids these days, and I would say it’s an even bigger problem for kids with disabilities.  After all, kids who play soccer or attend dance classes at least get a chance to interact with their peers and have fun, while kids in therapy are usually isolated inside a room with a therapist, and while this might sometimes be tolerable, in my experience, it is rarely fun.

These sacrifices might be worth it if physical therapy helped kids with cerebral palsy, but according to the literature, this is unclear.  It’s not exactly a surprise to me that PT may not work for kids with CP; after all, I’ve watched it not working for my daughter ever since she was 3 months old.  Back then, she could hold her head up for ten seconds.  Since then, every therapist has promised to improve on that.  “Oh, we’ll definitely work on head control,” each one says, as if she is the first to address this problem.   Six years and seven therapists later, how long can Chloe hold up her head?  Ten seconds.

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One Response to “Pascal’s therapy wager”

  1. Heather Says:

    I love a good god conversation. You make an interesting comparison here.

    I have a friend who’s son has been in the state system for being premature and some (not too obvious) social/talking delays. It was free and my friend really likes free things.

    She has spent so much time running him around and there is very little to show in the way of progress. This is not a person with CP but it demonstrates what you describe. l think what they spent time trying to teach him things that may not have interested him so he didn’t put much energy in working on what felt best and natural to him. He’s still progressing slowly but he will get there.


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