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Evidence Based Practice
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Evidence Based Practice - August 17, 2006 3:11:00 AM
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yarringtonpt
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From: Waynesville, NC
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I am a new poster, so I beg the pardon of the vets who may have discussed this topic in great detail in the past. I recently got out of 8 1/2 years of hospital-based, Physician-owned, and corportate practice and am happily in private practice. For the first time I feel like I can get more deeply connected with my profession.
From another thread, I wanted to spin off on the topic of EBP. I am not going to presume that I am as well read as some of you out there, so some of my questions / opinions are probably hypothetical. But I hope to spur some discussion on this topic as we can all agree on its importance.
The main question I have surounding EBP is not should we do it or why should we do it, but how we should do it. The challenge, as I see it, is demsonstrating effective treament for conditions that often require us as competent clinicians to evaluate and treat both the intrinsic and extrinsic factors that are impacting our patients' conditions. Also, we all know that we all "get people better", perhaps by different approaches. But the outcome may be the same.
Now some have said that just because someone says they are better, it is not necessarily so. How are they in 1 year, 2 years? This is all valid, but is it real world? What we have to go off of are outcomes measures, disability questionairres, and the physical and functional goals we set with our patients. When these are met, we call it successful.
I think that some of us and payors such as CMS may want to compare our practice to that of medical doctors. We will only be reimbursed by what we can back up. Well, I quite frankly don't want to be told by CMS that I can only use one particular Transverse abdom. exercise on a patient with back pain, because of one study. My questions is: What is the best way to measure successful treatment for a patient with low back pain that we may treat with exercise, manual therapy, orthotics, body mechanics training, taping, etc? What helped? What did not?
In medicine, physicians have luxuries that we do not. They keep and follow patients for years. We do not. We have to have permission, a referral or prescription (As I am in the US, I can only speak of our situation), a functional limitation, in order to evaluate. When a physician treats someone with hypertension, they choose a medicine an can control for the treatment. Although the lifestyle factors have an impact, no doubt, on the success of the treatment - they know what treatment helped or did not.
I get frustrated, as many of you must, whenever I see a study comparing chiro and PT for back pain that finds that PT is not effective. We come to find that only flexion exercises were performed. This may be a great way to find out if one treatment works for a diagnosis, but this is just not how our profession works. None of us would presume to pigeon-hole ourselves and put our patients in jeopardy by choosing one treatment for a diagnosis. First of all we treat what we see, hear, feel, and assess - not the diagnosis. Pick up McConnell's book on a team approach to patellofemoral pain. We should assess and treat foot posture, STJ mobility, posterior tib strength, hip ROM, glute medius strength, the ever popular VMO, balance, and the list goes on. Why, because the intrinsic and extrinsic factor can and often do all contribute to the problem.
So, how do we study and prove what we do without limiting what we do. Before the alarmists spout off, I am just talking about "proven techniques" and not outer-edge stuff like craniosacral, Total Motion Release, Simple Contact, etc. In the same breath, I am not knocking the unkown either - but those may be topics of other discussions.
I look forward to the replies. Forgive the typos and length of the post.
Eric
_____________________________
Eric Yarrington, PT, MPT, OCS
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Re: Evidence Based Practice - August 17, 2006 3:27:00 AM
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Jon Newman
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From: Amherst, WI
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Eric,
Can you define what "outter-edge stuff" means? What leads you to lump these things together as a group?
I have to think it is simply for lack of an double blinded RCT, preferably one that has been reproduced versus a lack of evidence underpinning the concept. If that is the case you could also add many other widely used PT approaches to that list.
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[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Evidence Based Practice - August 17, 2006 4:15:00 AM
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srcase
Posts: 551
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From: Michigan
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[QUOTE]So, how do we study and prove what we do without limiting what we do. [/QUOTE]Quick answer: By becoming consumers of research and by conducting research.
Eric,
I've been asking the same questions for a while now. It was a large part of why I chose to go back to school to earn my DScPT degree. Part of the problem is that there is so much about PT that we don't have research for, and the other part of the problem is that there is already so much out there, it is difficult for a busy, working professional to keep up on it. Fortunately, we are in a great time in our profession where, with the use of the internet, we can find out about almost anything. Whether or not a treatment technique is "outer-edge" is a whole separate discussion. On the other hand, one must be able to objectively review the literature and determine whether or not the methodology is sound, whether it can be generalized to our patients, and utilize the best evidence available in practice, keeping in mind the patient's values and our own limitations as clinicians. I guess what I'm trying to say is welcome to the world of PT today.....we are in our infancy compared with medicine, but it sure is an exciting time to be practicing!
Sarah
p.s. Did anyone notice that I used the quote feature for the first time...I'm so proud of myself!
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Re: Evidence Based Practice - August 17, 2006 4:29:00 AM
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interstella
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From: UK
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Hey Eric,Ive just typed all this out in answer to your initial question 'how do you do EBP" I dont think Ive answered you actual question, but as Ive typed all this out Im going to post it anyway! :D
Mt 'take' on practice is, it's a 'messy' and complicated process, no patient is exactly the same, one may get better in a month, whilst the other may take 3. Scientific research is a comparatively clean and tidy, it can provide you with a wealth of information, but will never give you all the answers, you have to use your clinical experience, communication skills, intuition etc.
The most important skill to develop is critical appraisal, if I read an article I need to ascertain the quality of the research, if its a well executed study, then I may feel that it is important to intergrate the ideas into my practice. If its not a well thought out study, then I can disregard it.
Another point is the 'weight of evidence' ie how many studies are there? If there is just one, then I may note an interest, but I wouldnt necessariy change anything. For example a few years ago, there had been some research which suggested that treadmill training was useful in paediatric therapy, I thought this was interesting. Now there have been a fair number of well conducted studies and I would consider purchasing one.
Finally, is the methodology sound and does the method match the research question, to study a treatment effect, it really needs to be a well conducted randomised control trial.
It is a difficult balancing act - we mustn't forget how important our clinical experience and the individual patient are when we choose our treatment
Hope that kinda answers your question!
Best wishes
Holly
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Re: Evidence Based Practice - August 17, 2006 4:31:00 AM
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interstella
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From: UK
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that should read my take.... Im sure there are a 100 other typos!
Very impressive Sarah!
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Re: Evidence Based Practice - August 17, 2006 4:53:00 AM
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yarringtonpt
Posts: 112
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From: Waynesville, NC
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Jon:
Outer-edge was a bad choice of words, forgive me. I was not trying to make a distinction between what some may call alternative forms of PT (like the ones I listed)and the more traditional exercise and manual therapy based techniques. Perhaps I mean the ones that are more researced. I don't mean to lump anything together, that would be inappropriate.
Sarah:
I agree. The challenge I see is that we can see research for seperate clinical treatments, but is there enough research grouping them together for different patient presentations. We may know that joint mobs reduce hypomobility and maybe centrally modulate pain for some one with back and leg pain, but what happens to the validity of the treatment when we introduce stabilizaion, body mechanics, etc.
To use a cliche, how do we preserve the art of what we do and the often highly individulaized treatments we use. In other words, we'll never be a profession that uses one treatment for one diagnosis, I hope. MAybe we'll find the best treatments for the all of the problems that a patient presents with a certain diagnosis.
I'm proud of your use of the quote feature; I have no idea how to use it. Are you proud that a new poster "stuck around" beyond the TMR topic?
Typing between patients is tough. I apologize if my posts are choppy.
Thanks,
Eric
_____________________________
Eric Yarrington, PT, MPT, OCS
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Re: Evidence Based Practice - August 17, 2006 5:04:00 AM
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Karie
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From: Wisconsin
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I too Eric would be interested in how to assess effectiveness after discharge. Surveys are never accurate due to rate of return. It is subjective in nature as well. I feel that is more of an indicator of the effectiveness of treatment in the long term. What happens between initial evaluation and discharge of course has importance and validity, that goes without saying. But, I am sure all of us have had the patient that was at a different PT office and then later comes to our office with the same complaint, and vice versa. This is where I think we truly find how long range our treatments really effect a permanent or manageable change, pending on the condition.
Thanks for starting this Eric, I am very interested to learn from all of you what you are all doing.
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Re: Evidence Based Practice - August 17, 2006 6:20:00 AM
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yarringtonpt
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From: Waynesville, NC
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The other thing that came to mind when looking at medicine vs. therapy is that our treatment effectiveness is often dictated by both assesment and clinical judgement as well as the skill with which we administer the treatment. In medicine, clinical reasoning is there but the "skill" of the treatment is left to the effectiveness of the drug.
So, are joint mobs ever just joint mobs? Can they be when we consider differences in patient positioning, speed/rate/force, patient sensitivity, etc., etc.??
I have always tried to base my treatment approach, first and foremeost on anatomy/physiology/kinesiology. This allows us to assess and treat, continuously, as we work with our patients. So, the foundation is there for application of researched clinical treatments.
As I said in another thread, do we call treatment like this unethical or unfounded? If I know about a particular muscle and stretch it according to its anatomy, is it wrong if I've never seen the technique in research? Or, should we just look at whether or not stretching in general has proven results?
Thanks for all of the comments.
Eric
_____________________________
Eric Yarrington, PT, MPT, OCS
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Re: Evidence Based Practice - August 17, 2006 6:41:00 AM
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srcase
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From: Michigan
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Eric, you're being too hard on yourself. As a PT, you have the skills and background to make clinical treatment decisions based on the patient's presentation, and your knowledge of anatomy, etc. That's perfectly within your practice act. It is definitely NOT unethical. On the contrary, the fact that you are concerned about this topic at all tells me that you are probably a very ethical PT with a good dose of skepticism, which is a very important attribute when delving into EBP.
Physicians I've talked to admit that it would be a lot harder to study the effects of manual therapy, than pharmaceuticals for exactly the reasons you stated. How do you control for what type of force, how much, and for how long?? But believe me, people are doing it. At my school, there are PT's researching the effectiveness of the Kaltenborn/Evjenth system, instead of just teaching it as gurus and saying "it works because....". Kornelia Kulig out of UofCalifornia is doing research along the same lines. It's exciting stuff and I only know a very small percentage of what's out there.
Some websites are devoted to the review of studies and discussions of current evidence such as evidenceinmotion.com and Duffy's site PTUpdate.com. APTA has some new resources too, although I can't remember what they are at this moment (brain fart). So, like I said....you can ride the wave or dive in and participate...or both...your choice!
Sarah
btw, check out the "UBB Code is enabled" link next to your quick reply box where you post a reply. It tells you how to do nifty things like quotes. Now, why did it take me so long to figure that out??
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Re: Evidence Based Practice - August 17, 2006 6:42:00 AM
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srcase
Posts: 551
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From: Michigan
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Karie,
Just a side thought: what about those patients who never seem to reach their goals, then you D/C after exhausting every possible treatment and find out weeks later that they have been painfree since stopping PT!! Those are the ones that make you go..hmmmm.
Sarah
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Re: Evidence Based Practice - August 17, 2006 6:46:00 AM
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proud
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Eric,
Great points. I think your observation about past research into Physiotherapy treatment is excellent. Pysiotherapy is not "TrA and multifus" training for everyone and lets see if it works...
I have mentioned in the past about why reliablity within our own assesment findings is so crucial( and why I question TMR...but that is neither here nor there). Let me give you an example of why our diagnostic reliability is so important, see if you follow( an example I have read before and reproduce verbatim):
["Suppose a doctor developed a nitroglycerin tablet for treating chest pain. Suppose further that at this point in time,the medical profession has no useful diagnostic test ,beyond self-reported symtoms, to determine who may have heart trouble, and therefore, every patient with a complaint of chest pain is considered a canditate for nitroglycerin therapy. Suppose further that the incidence of heart problems in a population of chest pain patients is 10%, with the remaining 90% having chest pain for a variety of other causes. If nitroglycerin is effective in 90% of the heart patients, it would be only 9% effective in the at-large population of patients with chest pain, and would therefore be discredited. Poor diagnostic methods would have resulted in that therapy with 90% efficacy for a specific subgroup having been incorrectly estimated to be only 9% effective...]
SO! BEFORE any randomized trial, we need to build a foundation of solid relaibility studies, THEN, use reliable assessment procedures to identify valid subgroups, THEN perform the RCT's.
Otherwise volumes of studies will continue to neglect important inclusion criterion and result in volumes of accumulating "evidence" suggesting that no real difference between treatments exists and that "NO treatment"(natural history) is the most cost effective route! Even though we all know this observation is incorrect.
So the advise of many in our profession is that we all must be diligent in recognizing the inherent problem with using unreliable assessment techniques.
And perhaps put the best way by Sarah C: "By becoming consumers of research and conducting research."
Regards,
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Re: Evidence Based Practice - August 17, 2006 7:47:00 AM
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yarringtonpt
Posts: 112
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From: Waynesville, NC
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proud:
I could not agree more. If I understand you correctly, I agree that assessment is the foundation for everything that we do. Because of this we can base treatment on anatomy, physiology, kinesiology, etc.
I'm not trying to rehash TMR with you, but that was the basis of my arguement. If I have a sound, scientfic neuromusculoskeletal basis for a treatment (but not the specific movement in this and other cases), does that fall outside the realm of how we are choosing to define EBP?
Active ROM of major joints to effect changes in myofascial restrictions and pain is not new to us. We know that pendulum swings make shoulder patients feel better, probably due to the oscillation effect on mechanoreceptors, right. So, if we use our knowledge of anatomy, etc. to guide or treatments, by doing research are we just looking for the best ways to manipulate the anatomy to effect the best and most lasting positive changes?
Hate to keep comparing PT research to Medicine, but is easier for me to use as an illustration: Someone with an allergy to cat hair gets inflammation in the lungs ans asthma (we'll say that they are not allergic to anything else and do not have a virus/infection). They have asthma for one thing, they use medicine, they get relief.
When we see someone with knee pain, there may be 5 things contributing to there knee pain. So, I agree with proud - our assessments of what causes dysfunction may be as/more important than finding what treatments help certain problems. And, researching physical problems vs. diagnoses.
Great comments, everyone.
_____________________________
Eric Yarrington, PT, MPT, OCS
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Re: Evidence Based Practice - August 17, 2006 8:48:00 AM
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Karie
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From: Wisconsin
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I'm right there with you Sarah C.; lots more happening then we can always put our fingers on !
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Re: Evidence Based Practice - August 17, 2006 2:36:00 PM
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SJBird55
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Evidence based practice is described as combining the evidence in literature with the patient's goals and the clinician's expertise.
What evidence based practice means to me as an individual and the impact it has on me is that I need to stay current with published literature; I need to critique the published literature - assessments/treatments/outcomes/normative data/sensitivities/specificities/clinical prediction rules/probabilities; I have to somehow remember published stuff that is pertinent to the types of patients that I treat (a tough task); I have to take the time to search out answers as best as I can on a more frequent/regular basis; I will change my behavior and performance based on published literature (even tougher to remember I want to do something different); I expect what I know now will be different in 1 year, 6 months, 2 weeks and I will again need to alter my behavior and performances. This means that I shouldn't necessarily be practicing the exact same way in 5 years. Ths means that I will and should potentially have definite chunks of time when I am not completely comfortable in the clinic because I won't always be able to fly in "auto-pilot" because I will be incorporating the changes that should bring more effective results. It also means that I continue to utilize standardized outcome measures and analyze results. I guess that's more of a "personal" view of evidence based practice, but that's how I've defined it for myself.
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Re: Evidence Based Practice - August 17, 2006 3:34:00 PM
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ginger
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From: Melbourne Victoria
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Proud , I was particularly impressed with the thoughts you expressed about reliable assessments into subgroups for those being examined and treated during trials/RCTs etc. Your example brought home to me a topic we have explored from time to time here , though I hope we can in detail again.
My fond wish would be that trials for continuous mobs and its effects on a variety of musculoskeletal conditions may begin in the summer here. I am currently involved in training a group of 40 undergraduates in the method. Expect to be able to have many of this group be available to participate in RCT type evals from december. The variables within spinal pain groups are potentialy large, though I think for my type of study fall into three main groups.
HX of trauma, no trauma and hx of disease.
within the no trauma group ( the most likely to be part of my first study group), those with hx of 12 months or more, and those within twelve.
For those within twelve months,
those who c/o pain that falls within a particular locality, ie lumbar, thoracic and cervical.
Beyond those subgroups Proud, Ive yet to determine accurately, the likely type of candidates that fit , ( also no decision yet made on the musculoskeletal condition first considered , though I'm biaseed toward PFS )
Any thoughts on these issues gratefully recieved and considered. Perhaps a new thread.
Cheers
Any discussion of
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Evidence Based Practice - August 18, 2006 1:43:00 AM
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Alex Brenner PT MPT OCS
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Eric,
Have you visited the evidence in motion website? It is an entire website dedicated to this very topic and is run by several therapists who are top leaders in our field in the area of research and integration of evidence into our practice. Check it out when you get a chance.
[URL=http://www.evidenceinmotion.com]www.evidenceinmotion.com[/URL]
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: Evidence Based Practice - August 18, 2006 3:29:00 AM
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yarringtonpt
Posts: 112
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From: Waynesville, NC
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Thanks Alex. I have been there a few times, but just recently discovered it. I need to dive in deeper.
Eric
_____________________________
Eric Yarrington, PT, MPT, OCS
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Re: Evidence Based Practice - August 20, 2006 6:09:00 PM
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mcap56
Posts: 618
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From: New York, NY
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Hi Eric:
We can't tell you how to practice EBP in one post. However, there are some misconceptions about it that may be usefult to clear up.
1. Don't assume that medicine is generally practiced with regard to EBP and PT is not. A lot of what is done in healthcare, every day, in this country has very little evidence to support it.
2. One primary advantage MDs have is that they have other people that do the research for them. MD/PhDs split their time between clinic and research. And research PhDs work on problems that will eventually make their way into the clinic. Finally, there are the resources of the pharmaceutical industry. They sink billions into research and development. There is an entire research apparatus that we don't have.
3. Everyone talks a good game about performing RCTs but ask anyone who has ever tried. Getting patients is almost impossible. What can you offer a patient to get them to consent to a PT RCT where they may get a placebo? Most people would just prefer to get the treatment they want, through their insurance. Pharmaceutical companies can offer money or the chance to try a brand new treatment/drug. Same with academic medical center RCTs. Patient recruitment is very, very difficult.
4. Most importantly, EBP is an attempt, a process - not a noun. You can't say one person is an EBP practicioner and someone else isn't. Only one who tries to apply EBP and who does not that. It's the trying. That's what EBP is all about. EBP, as I see it is an attempt to have an awareness of the research, or lack thereof in support of what you are doing. If there are no studies to support what you are doing, but you have a sound physiological rationnale and some clincal rationnale, you are still practicing EBP.
For the clinician start with literature reviews and meta-analyses on a particular topic and then work your way down to RCTs, cohort studies, case series, etc. Make a note of how many of each there were and what each one showed, in general (Benefit v. no benefit).
If you want to get involved, make sure you joing the APTA and get to one of the conferences. There is some very impressive research out there. See how you can get involved.
Marc
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Re: Evidence Based Practice - August 20, 2006 8:31:00 PM
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nari
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From: Australia
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Marc
Well said!! Especially #4.
Nari
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Re: Evidence Based Practice - August 21, 2006 7:24:00 AM
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yarringtonpt
Posts: 112
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From: Waynesville, NC
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Marc:
Great comments. This really sums up what I guess I have been trying to say. It is a process and a difficult one at that. I, like Nari also like and agree with what you stated in #4. Others, I feel are being too literal with EBP - If a specific study doesn't show that treatment X works, then don't waste your time. I prefer, like you, to make sure that our theories and physiological basis for treatment is sound. This usually weeds out the "fringe" treatments that people refer to as non-proven.
Eric
_____________________________
Eric Yarrington, PT, MPT, OCS
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