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Evidence based practice
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Evidence based practice - April 26, 2000 11:23:00 PM
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Rennie Maeda
Posts: 10
Joined: December 15, 1999
From: Manhattan Beach
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This is in part response to comments on the Frequently Asked Questions thread.
In September 1998 and March 1999, Joe Godges and Gail Deyle edited two volumes of Orthopaedic Physical Therapy Clinics of North America entitled Upper and Lower Quadrant: Evidence-Based Description of Clinical Practice. In it the authors attempt to write about evidence based practice for different regions of the body. I have several questions for all those who purport to practice evidence based physical therapy.
1) Have you read these articles and what did you think of them?
2) How do you rate the evidence?
3) What kind of evidence is needed for you to try a different treatment or evaluation technique?
4) What kind of evidence is needed to get you to stop using a specific treatment or evaluation technique?
5) What do you consider the minimal amount of time and money a physical therapist should spend in order to continue to be up-to-date with evidence based practice?
6) How can the APTA help to achieve these goals?
My answers are:
1) I read them and am not surprised by the variablility in how each author answered the same general question about what is the evidence for physical therapy for a specific region of the body.
2) I have proposed an adaptation of ratings for evidence by the Quebec Task Force on Spinal Disorders. I broke it down into two ratings/classifications. One for evaluation techniques and one for treatment interventions. They are offered as a starting point for discussion.
3) Doesn't take much to make me try a technique. It's got to make sense (to me) and someone has to say it works. It's best if I see it "work." My caveat, when it is just based on expert opinion, is to compare your therapist-patient situation to that of the "expert" therapist and his/her patient. This should be on many, many levels.
4) Same as above, I compare the study or the expert opinion to my situation with my patient. Multiple, appropriate, studies may make me consider to stop using a treatment technique, but maybe not. For example, I do continue to use the kinetic/march/Gillette sacroiliac mobility test despite studies touting it's unreliability. However, I do the test with certain modifications to the technique which I feel should improve reliability. I do not believe that doing a Medline search and reading the abstracts constitutes scientific validity. It is a good start though.
5) I think every therapist should read Physical Therapy journal and one other journal in their specialty area at the very least (e.g. JOSPT).
6) I feel that it is the responsiblity of the APTA, at the very least, to publish position statements on the use of interventions which have been proven through multiple studies to be harmful or not beneficial to specific patient populations. Orthopaedic Practice does have a section entitled Evidence Express which should give some direction.
What do y'all think? What are they teaching you in school?
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Re: Evidence based practice - April 27, 2000 9:05:00 AM
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mcap
Posts: 652
Joined: February 8, 2000
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Rennie:
I like your post and agree with many points. The ratings systems with a number of "stars" either in favor or against seem to be popular now (see United Kingdom Guidelines or AHCPR). We don't fare well in those because of the emphasis on RCTs. PT doesn't have enough of those.
I will differ with you on one point. You place the most importance on whether you see the technique or test work with your patients. I contend that it is precisely these judgements that we must avoid making!!!
How do you know that your intervention is not a placebo or short-term only response. The low back is an example.....virtually every therapy has been shown to be of short-term benefit only. This includes Chiropractic, McKenzie, Osteopathic, NSAIDs etc. We need to find something that works or we will loose the referrals.
As for the Gillet test....the orthodox medical literature dismisses those tests not only based on reliability but on the biomechanics of the SI joint. It does not move in such a way that can be palpated - we are talking one or two degrees and a couple of millimeters of translation...That's it!!!! (Bogduk 1997).
mcap
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Re: Evidence based practice - April 28, 2000 4:23:00 AM
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Barrett
Posts: 967
Joined: July 28, 1999
From: Cuyahoga Falls, Ohio
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I'm surprised that this discussion has yet to mention Richard Di Fabio's series of editorials in JOSPT during the past year.
He makes a very convincing argument that the idea that evidence based actually exists is a "myth," primarily because the criteria used to determine the appropriateness of evidence is unclear. He says, "There is room for alternative interpretation of the 'evidence' but we are set on a misguided quest for the truth, engineered by a politically correct movement to agree on the 'evidence.'" He says a lot more than this, and I'd highly recommend a careful reading of his comments.
When someone asks me if my own practice is evidence based, they usually mean, "Do you have a study proving that what you do works?" I don't, of course, and these kinds of studies are extremely rare. Laurita Hack (the director of the program at Temple, a highly regarded expert on the matter of research and a primary author of The Guide)says such research "is not for the faint of heart."
I can honestly say that there is excellent literature justifying the nature of my theory and technique. What I do makes sense, and I'm happy to demonstrate that with research published in peer reviewed journals. At present, this is probably the best any of us can do.
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Re: Evidence based practice - April 28, 2000 7:34:00 AM
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Andrew M. Ball, MS, PT
Posts: 500
Joined: October 8, 1999
From: Chapel Hill, NC, USA
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Darn,
I was hoping that I could get away with not having to discuss the DiFabio article. You're right Barrett, it does take a little bit of the steam out of my charge toward evidence-based practice.
I'm surprised that none of the folks here on this forum who want to see me take a serious taste of my own medicine have not brought it up . . . it would take some serious steam out of my arguments and significantly weaken my "house of cards" regarding evidence-based practice.
I'm not going to give others the ammo that they need to ambush me . . . but if that motivation is what others need in order to take a closer look at some of the literature . . . then so be it (LOL!). I've got pretty thick skin, I can take it!
Drewfus
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Re: Evidence based practice - April 28, 2000 9:36:00 AM
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Barrett
Posts: 967
Joined: July 28, 1999
From: Cuyahoga Falls, Ohio
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Well, a new low by Bobcat.
Di Fabio and Hack are among the finest clinicians, theorists, educators and writers our profession has ever known. Anybody unwilling to take their opinion into consideration is, well, a fool.
Would you say what you just said in public? At a PT meeting? Without a mask on? What on earth makes you think a post like this advances the discussion?
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Re: Evidence based practice - April 29, 2000 6:16:00 AM
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mcap
Posts: 652
Joined: February 8, 2000
Status: offline
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Barrett:
I am sure this will draw a reply in which you state that I do not understand what you are talking about!!! But I am sorry - I COULD NOT AGREE WITH BOBCAT MORE. I am sure he would say it at a meeting but if he didn't I sure would!!!!!
For me, he hit the nail on the head. Clinicians out there are trying different techniques based on obscure theories without any regard to science. It is absolutely unacceptable. Evidence based practice is difficult to acheive but we should at least try.
Would you have a loved one take a medication that has not been subjected to randomized controlled trials????? I don't think you would. But yet in PT having a theory that seems to make sense seems to be all that is needed. We are exempt from the very standards that we impose upon other people!!!!
200 years ago many clinicians would probably have told me that leeching treatment was based on a sensible principle. If there is a problem have the leech remove the fluids from the area. More recently, ulcer patients were told that they were under stress and ate too much junk food. Makes perfect sense right - except for the bacterial infection that was there.
This kind of thing happens in medicine all of the time. The difference is that they strive to discover the realities and base their practice on the best knowledge of the day.
We don't and it is NOT acceptable.
P.S. please direct me to the place on your site where there is a clear description of the neural tension theory.
Take care,
Mcap
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Re: Evidence based practice - April 29, 2000 6:53:00 AM
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Rennie Maeda
Posts: 10
Joined: December 15, 1999
From: Manhattan Beach
Status: offline
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Great comments by all.
From what I can see in our comments we all agree on the need for more evidence. (But none of us are doing clinical research (myself included) to improve the situation.)
If I may be permitted to oversimplify, some of us believe that the evidence is too flimsy to stop the use of our personal favorite techniques. (I will continue to use certain techniques because "they work for me and my patients.")
Some of us believe in "helping" others to think about the evidence by trying to "force" them to defend their practices. (I will use a lot of rhetoric to blast others even though in my practice I do not have a shred of scientific evidence which supports all that I do.)
Some of us believe that even with a lot of evidence (as DiFabio suggests with the safety of cervical manipulation) well intentioned experts cannot agree. (Therefore, no matter what I do I may be right.)
I graduated from USC in 1988. At that time we were taught that the evidence shows that no technique or modality has been shown to work in clinical trials. I left PT school with the depressing feeling that we have little to offer. Has anything changed? Let me know, especially new and future graduates.
By the way, to all of the frequent and not so frequent posters on the Forum, PT, JOSPT and Ortho PT Practice are all very interested in what we have to say. Stand up and be heard. Sorry Bobcat, you'd have to reveal yourself. [IMG]http://www.rehabedge.com/forums/smile.gif[/IMG]
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Re: Evidence based practice - April 29, 2000 1:54:00 PM
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Andrew M. Ball, MS, PT
Posts: 500
Joined: October 8, 1999
From: Chapel Hill, NC, USA
Status: offline
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Forum,
I'm not sure that I agree with all of that Rennie. My pet techniqe (PWB-GT), which is still considered "alternative" by most clinicians . . . is considered a breakthrough by researchers. It is very well researched, and the literature is only getting stronger by the day.
You are correct in saying that not many PT techniques work any better than another, be it PNF, NDT, whatever. There are a few things that we do well though:
Mayo NE. The effect of physical therapy for children with motor delay and cerebral palsy. A randomized clinical trial. Am J Phys Med Rehabil, 70(5):258-67 1991 Oct
A randomized controlled trial was undertaken to compare the effects over 6 months, of weekly (intensive) and monthly (basic) neurodevelopmental therapy on the motor development of young children with suspected cerebral palsy. Subjects were no older than 18 months when referred for physical therapy because of a motor delay. All those meeting specified criteria were assessed on seven motor development tests: reflex activity, postural reactions, gross motor ability, fine motor skills, mental functioning, dominance of abnormal movement patterns and ability to participate in activities of daily living. The average proportional change in aggregate motor development for the 17 infants on the weekly (intensive) regimen was substantially better than that for the 12 on the monthly (basic) regimen, after adjusting for the child's age, whether the child was born at term or not, and mother's education. A statistical test led to an equivalent of a Student's t = 3.49, which with 24 df was associated with P = 0.0019 (two-sided).
O'Connell DG ; Barnhart R Improvement in wheelchair propulsion in pediatric wheelchair users through resistance training: a pilot study. Arch Phys Med Rehabil, 76(4):368-72 1995 Apr
Six children, three with cerebral palsy and three with myelomeningocele, participated in a progressive, 8-week, circuit muscular strength training program. The program was designed to improve wheelchair propulsion, an important functional outcome. Subjects performed three sets of six-repetition maximum (6-RM) upper body strength exercises, three times a week. Exercises included shoulder flexion, extension, abduction, internal and external rotation, elbow flexion, extension, and shoulder flexion/elbow extension (bench press). Subjects exercised quickly with little rest between each set for approximately 30 minutes per session. All children used wheelchairs extensively and participated in a 50-m, and a 12-minute wheelchair propulsion test before and after the 8-week program. The sign test was used to determine if statistically significant (P < or = .05) wheelchair propulsion or 6-RM changes occurred over the training period. Subjects improved significantly (P < or = .031) in all muscular strength (6-RM) measures and the 12-minute distance test. There was a trend toward improvement in the 50-meter test, although this change was not significant (P < or = .05). The results indicate that progressive resistance exercise training seems to improve muscular strength and wheelchair performance in selected disabled children.
Andrade CK ; Kramer J ; Garber M ; Longmuir P. Changes in self-concept, cardiovascular endurance and muscular strength of children with spina bifida aged 8 to 13 years in response to a 10-week physical-activity programme: a pilot study. Child Care Health Dev, 17(3):183-96 1991 May-Jun
Eight children with spina bifida trained for about 1 hour a week for 10 weeks, while the five control-group children did not participate in the physical-activity programme. The exercise group improved significantly on five of eight criterion means, while the control group showed no significant improvements.
Bensahel H ; Guillaume A ; Czukonyi Z ; Desgrippes Y. Results of physical therapy for idiopathic clubfoot: a long-term follow-up study. J Pediatr Orthop, 10(2):189-92 1990 Mar-Apr
Physical therapy without anesthesia or plaster casts was used to treat 338 cases of clubfoot (CF). Our technique is based on progressive sequential manipulations at birth. We first reduce the varus and later the equinus component of the CF. The gentle stretches used in this technique are complemented by active physiotherapy stimulating the muscles, and then a simple splint is suited to the foot to fix its degree of realignment. When used alone, this technique achieves 77% good and fair results.
Kelpper SE. Effects of an eight-week physical conditioning program on disease signs and symptoms in children with chronic arthritis. Arthritis Care Res, 12(1):52-60 1999 Feb
Children and adolescents with chronic polyarticular JRA can improve their aerobic endurance through participation in weight-bearing physical conditioning programs without disease exacerbation or increased pain, and may achieve decreased joint signs and symptoms through increased physical activity.
Guidera KJ ; Hontas R ; Ogden JA. Use of continuous passive motion in pediatric orthopedics. J Pediatr Orthop, 10(1):120-3 1990 Jan-Feb
Continuous passive motion (CPM) was used to maintain or gain hip and knee range of motion in 18 postoperative or postinjury pediatric orthopedic patients. Continuous passive motion was started in the early postoperative period and augmented with physical therapy. The device was well-tolerated in 16 of the 18 patients. In all but one, motion was improved with a progressive decrease in joint pain. In these patients, CPM was found to be a valuable tool in rehabilitation.
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The bad news, is that there is a single technique that seems to be demonstrated as being at least twice as effective and infinately more efficient than traditional therapy if your goal is independent ambulation, ambulation speed (important 'cause that's closely liked with morbidity), and yes . . . EVEN BALANCE. That's PWB-GT, and very few people use it. Here are the references:
Richards CL, Malouin F, Dumas F, Marcoux S, Lepage C, Menier C. Early and intensive treadmill locomotor training for young children with cerebral palsy: A feasibility study. Pediatric Physical Therapy 1997; 9: 158-165.
Visintin M, Barbeau H, Korner-Bitensky N, Mayo NE. A new approach to retrain gait in stroke patients through body weight support and treadmill stimulation. Stroke 1998; 29: 1122-1128.
The best study on hemiplegic gait training. 100 patients randomized into two groups. The results are difficult to argue with. This study examines traditional PT group against PWBTT & traditional PT group.
Hesse S, Bertelt C, Jahnke, MT, Schaffrin A, Baake P, Malezic M, Mauritz KH.. Treadmill training with partial body weight support compared with physiotherapy in nonambulatory hemiparetic patients. Stroke 1995; 26: 976-981.
This is the ABA study showing the dramatic effect of BWS gait training. Unfortunately, with only seven patients.
Hesse S, Bertelt C, Schaffrin A, Malezic M, Mauritz KH. Retoration of gait in nonambulatory hemiparetic patients by treadmill training with partial body-weight support. Archives of Physical Medicine and Rehabilitation 1994; 75: 1087-1093.
Nine nonambulatory patients who had “failed” after 3 weeks of PT dramatically improved with only three weeks of BWS gait training.
Hesse S, Malezic M, Schaffrin A, Mauritz K. Restoration of gait by combined treadmill training and multichannel electrical stimulation in non-ambulatory hemiparetic patients. Scandinavian Journal of Rehabilitation Medicine 1995; 27: 199-204.
Hesse S, Uhlenbrock D, Sarkodie-Gyan T. Gait pattern of severely disable hemiparetic subjects on a new controlled gait trainer as compared to assisted treadmill walking with partial body weight support. Clinical Rehabilitation 1999; 13: 401-410.
Hesse also has a new one with regards to kids with CP in the new (March, 2000) archives of physical medicine. The kids traditionally treated did not improve on the GMFM . . . those treated with PWB-GT improved GMFM scores for BOTH standing and walking subdommains by 47% and 50% respectively. Hard to argue that PWB-GT does not work.
Hope that opens a few eyes
Drew
P.S. For the record, I'm a full time clinician, and a full time Doctoral student . . . and I am actively invovled in research trying to solidify my opinion that the only pediatric PT that should be reimbursable for specific neurologic injuries (just about all save complete SCI), should include an intervention program that includes PWB-GT. Traditional pediatric PT's have about 12 months before I publish and all hell breaks loose in pediatric PT. When the smoke clears, the profession will be better for it.
[This message has been edited by Andrew M. Ball, MS, PT (edited April 29, 2000).]
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Re: Evidence based practice - April 29, 2000 4:40:00 PM
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Rennie Maeda
Posts: 10
Joined: December 15, 1999
From: Manhattan Beach
Status: offline
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I agree with you Drew, "physical therapy" has been demonstrated to be effective in many studies for orthopedic diagnoses (e.g., s/p arthroplasties, fractures). "Specific techniques are only now being to be shown to be more and more effective.
Perhaps the Forum could be used as a source for sharing of information between clinicians who are interested in reading more about the evidence for "physical therapy" for specific diagnoses and the evidence for "specific" treatment and evaluative procedures for these diagnoses.
There could be a new thread for "Evidence Based Practice". Subheadings for the Specialty Areas. Tertiary headings for diagnosis within each specialty area.
Then under each diagnosis, there could be one thread to share information, and another thread to discuss the information.
EVIDENCE BASED PRACTICE
I.Orthopedics
IA.Patellofemoral Dysfunction
IA1.Thread for physical therapy and patellofemoral dysfunction
IA1a.Thread for listing citings & abstracts
IA1b.Thread for discussing the evidence
IA2.Thread for a specific technique and patellofemoral dysfunction
IA2a.Thread for listing citings & abstracts
IA2b.Thread for discussion of the evidence
Or some other way to organize discussions on the evidence. Just a thought, any others? You could even get PT schools to make it class projects to contribute to the listings.
[This message has been edited by Rennie Maeda (edited April 29, 2000).]
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Re: Evidence based practice - April 30, 2000 5:28:00 PM
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David Adamczyk
Posts: 305
Joined: March 14, 1999
From: Cleveland
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Rennie,
Your idea for a special Forum area dedicated to evidence based practice is great. I invite you and any other members to send me their ideas regarding the development of this Forum.
[EMAIL]Adamczyk@RehabEdge.com[/EMAIL]
[This message has been edited by David Adamczyk (edited April 30, 2000).]
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Re: Evidence based practice - April 30, 2000 8:23:00 PM
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Rennie Maeda
Posts: 10
Joined: December 15, 1999
From: Manhattan Beach
Status: offline
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Thanks Drew, I just gave my wife some of your references. She works in a clinic that utilizes the body weight support system to treat mostly adult neuro patients.
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