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The Philadelphia Panel
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The Philadelphia Panel - October 10, 2001 8:50:00 AM
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Barrett
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From: Cuyahoga Falls, Ohio
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“A growing number of healthcare practitioners advocate what they call ‘evidence’-based practice. It seems ironic that some advocates of this approach emphasize the usefulness of only one form of evidence: information gained from the statistical study of large groups of people. …If you want to know if a particular treatment works on the average, you need this kind of study. However, there is information that can never be gotten from doing this kind of research. Statistical studies will never tell you how a treatment works or how an individual functions, although it may suggest ideas. …Depending too much on group statistical methods thus promotes a generic approach…”
Bruce Kodish, Ph.D., P.T. in “Back Pain Solutions”
Yesterday I began to trudge through the latest edition of the PT Journal featuring the findings of the “Philadelphia Panel,” a group of clinicians, researchers and clinicians interested in neck, back, knee and shoulder pain. I have a lot left to read and maybe it’s not as bad as it seems to be just yet, but it appears that this group’s analysis of the evidence regarding the actual effect of many commonly used interventions is, well, non-existent. And I mean to a devastating degree. Take a look. Many of these procedures are steeped in tradition and locked into the protocols many departments established long ago.
What Kodish says above addresses this study to some degree but is probably insufficient to explain much of the success we seem (and I mean “seem”) to have doing things this panel has dismissed as having no effect.
For me personally the examination of many of these procedures is not relevant to my practice since I don’t do them anyway, but I know many fine therapists that do, and I’d like to know what they’re thinking in light of yesterday’s publication.
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Re: The Philadelphia Panel - October 14, 2001 5:48:00 PM
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PTupdate.com
Posts: 1490
Joined: October 8, 2001
From: Pittsburgh, PA USA
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I reluctantly sat down this weekend and began reading this issue of PT. Obviously, a lot of time and money went into this, and I am not sure exactly how I will benefit from this, or how our profession will benefit. Hopefully, some unscrupulous payor will not choose to deny payments for certain procedures based on some of this information! OK, so a study found that exercise is not significantly beneficial for acute LBP. Was their exercise administered exactly as mine? Were the exercises exactly the same, with the same equipment? I doubt it. In my own practice, I know what I have excellent success with, and what I would like to improve on. Unfortunately, this study does not help me. It does remind us as professionals that we need to be able to prove that some of our treatment do indeed work. PT is still a big cash-cow, and we are going to be on the re-imbursement chopping block eventually! There is not much doubt that PT works for multiple conditions, as evidenced by physician and patient support, and permission by the payors (often PT is a pre-requisite for the patient prior to any expensive diagnostic testing!). Most of us do not have the time and/or money to begin research projects. I have a huge list of studies I would like to perform, but 8 hours in the clinic and 5 on my website each day does not afford me that luxury!
John Duffy, PT OCS
[QUOTE]Originally posted by Barrett:
“A growing number of healthcare practitioners advocate what they call ‘evidence’-based practice. It seems ironic that some advocates of this approach emphasize the usefulness of only one form of evidence: information gained from the statistical study of large groups of people. …If you want to know if a particular treatment works on the average, you need this kind of study. However, there is information that can never be gotten from doing this kind of research. Statistical studies will never tell you how a treatment works or how an individual functions, although it may suggest ideas. …Depending too much on group statistical methods thus promotes a generic approach…”
Bruce Kodish, Ph.D., P.T. in “Back Pain Solutions”
Yesterday I began to trudge through the latest edition of the PT Journal featuring the findings of the “Philadelphia Panel,” a group of clinicians, researchers and clinicians interested in neck, back, knee and shoulder pain. I have a lot left to read and maybe it’s not as bad as it seems to be just yet, but it appears that this group’s analysis of the evidence regarding the actual effect of many commonly used interventions is, well, non-existent. And I mean to a devastating degree. Take a look. Many of these procedures are steeped in tradition and locked into the protocols many departments established long ago.
What Kodish says above addresses this study to some degree but is probably insufficient to explain much of the success we seem (and I mean “seem”) to have doing things this panel has dismissed as having no effect.
For me personally the examination of many of these procedures is not relevant to my practice since I don’t do them anyway, but I know many fine therapists that do, and I’d like to know what they’re thinking in light of yesterday’s publication. [/QUOTE]
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Re: The Philadelphia Panel - October 15, 2001 4:16:00 AM
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Andrew M. Ball MS MBA PT
Posts: 271
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From: Chapel Hill
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I disagree. Strenuously. As an MBA I disagree with spending money on techniques that have not been proven, and as a PT I disagree with the degradation and perversion of our profession because a group (perhaps even a majority) of PT's, "know what they see," not letting evidence, literature, or science get in their way.
Ptupdate.com misses the point completely. Hopefully, some reasonable third party payer WILL look at this study and begin to deny reimbursement for unproven techniques. It DOES have direct impact upon your practice as a physical therapist because the Panel is NOT a discussion of a single study, but rather a commentary on the ENTIRE BODY of current research on various treatment techniques. Financial incentive to use what's been proven will help elevate the respect of physical therapy from technician to professional in ways that the DPT cannot.
According to the research, ALL of the research, the dramatic effects that many claim to see by using exercise in the acute stage of back pain would occur with or without their help. If it would occur without the PT's help, as the evidence suggests, then they have no business charging for the service.
If an individual therapist somehow believes that his or her approach is somehow different, it is now his or her professional responsibility to begin collecting data. Lack of time is not an excuse. It's a cop out, and I for one am tired of hearing PT's claim not to have enough time to conduct research due to their busy clinical schedules. They adopt a "bill now and ask questions [e.g. conduct efficacy research] later, not realizing for one second that their testimonials that, "I know what see" are worthless. In the absence of evidence (not in one or two studies, but in the ENTIRETY of literature on the subject), they're lucky to be getting paid at all.
Drew
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Re: The Philadelphia Panel - October 15, 2001 4:51:00 AM
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Barrett
Posts: 967
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From: Cuyahoga Falls, Ohio
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Andrew, glad to see you here. As always, your reply gets to the point and I'm not especially sanquine about the situatuion improving for any of the parties involved.
Why such a massive division between those who see the same patients, hear the same stories and collect the same paychecks? Is it possible that the language of science, ironically enough, is often insufficient to describe the total experience of management from either perspective? While this idea intrigues me, I'm acutely aware that using language itself to describe alternate "realities" is a slippery slope, leading us toward the realm of postmodernism and deconstructionism. I don't care for references to things like the patient's "journey" in order to rationalize a variety of alternative methods that make no sense otherwise. On the other hand, wouldn't someone with acute back pain typically appreciate having their fears allayed by a professional, their person touched by a fellow human being and their complaint heard with some empathy and compassion? Might they not complain if they were only told to "resume normal activity" as described in the article (what is "normal" anyway?)?
We try and try to measure our effect, and it's not easy. This doesn't mean we should stop trying, of course. I'm one who doesn't, and I'll be the first to admit that.
[This message has been edited by Barrett (edited October 15, 2001).]
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Re: The Philadelphia Panel - October 15, 2001 8:55:00 AM
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Andrew M. Ball MS MBA PT
Posts: 271
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From: Chapel Hill
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I'll comment on one point and let others a chance to become active in the discussion.
Gusty play there Barrett. I agree that there is value in a patient coming to a PT to have fears quelled. That may justify an initial evaluation in even the most perverse of circumstances. Many professionals offer free consultations in the hopes of generating increasing "real" and ethical business. Decisions to proceed with treatment should be at this point be guided by the Philly Panel.
What are your (meaning not just Barrett, but all RehabEdge members) thoughts on the subject?
Drew
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Re: The Philadelphia Panel - October 15, 2001 9:46:00 AM
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Barrett
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From: Cuyahoga Falls, Ohio
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Drew,
You say, "I agree that there is value in a patient coming to a PT to have fears quelled."
Perhaps the operative word here is "value." Surely, fear contributes considerably to pain, and if our expertise and simple presence are enough to reduce it (and I mean because we are professionally trained and the patient is aware of this) the pain will probably be reduced. Why should this only count at the first visit? Pain doesn't leave all at once, and neither does fear. (In fact, pain never "leaves," we just act differently, but that's another discussion) A lot of exercise "works" because it restores the patient's confidence in movement, not because it actually stretches or strengthens anything relevant.
If we're actually acting most effectively as encouraging, college educated companions, rather than truly as guides the findings of this panel shouldn't surprise us. Maybe that's why the findings don't surprise me very much. There is a difference however between accepting this report and deciding how to treat patients when the methods you choose are not mentioned here.
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Re: The Philadelphia Panel - October 15, 2001 11:05:00 AM
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Andrew M. Ball MS MBA PT
Posts: 271
Joined: September 30, 2001
From: Chapel Hill
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That kinda treads upon the field of psychologists specializing in pain management. Though PT's tend to be very caring, I'm not sure if we've got the psych training to be meddling in pain reduction relative to fear . . . esp. if that pain will reduce with our without the influence of the PT.
True, PT can make the process more comforting, but is that what we are in the final analysis? Glorified Mommies and Daddies who kiss the boo-boo and make it feel all better?
Drew
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Re: The Philadelphia Panel - October 15, 2001 12:24:00 PM
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Barrett
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From: Cuyahoga Falls, Ohio
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Drew,
This characterization is pejorative and inaccurate. When I say that movement is therapeutic because of what it teaches us I am not playing psychologist, I'm speaking about something we know to be true but seems to be of no interest to the Philly Panel. None of my patients would describe me as either paternal or maternal.
[This message has been edited by Barrett (edited October 15, 2001).]
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Re: The Philadelphia Panel - October 15, 2001 12:31:00 PM
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jma
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From: NY
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Hello,
As a new graduate, I am glad to see that a group of individuals are gathering data and trying to make sense of it. With regards to the what they found, I find it useful for future clinical decisions. I am not well expertised in what works and what doesn't yet, but a study like this does benefit those with little or no experience in the field. Many of you have experienced what works and what doesn't from years of practicing PT. Remember that there are no "offical protocols" to go by when going about making clinical decisions. However, this study helps us go in the right direction. If others, disagree with what this research group is saying, then they need to contribute to the research and prove otherwise. Group studies may have limitations but they must be done. Even many of you who do contribute to the literature will evenutally be grouped into a study to analyze the results. Contributions count but as a whole, not by itself.
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Re: The Philadelphia Panel - October 15, 2001 5:39:00 PM
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PTupdate.com
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From: Pittsburgh, PA USA
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Mr. Ball
I disagree with your statement that I "missed the point completely". I do understand the point just fine. Nor do I need you to tell me that my lack of time is not an excuse, but a cop out. You not know me, nor my personal schedule and my life. You are in no position to make any judgements, so be cautious on the ground you tread!
What we do as PT's is very hard to nail down in a study and conclude that "it does" or "does not" work. Perhaps instead of looking at one individual aspect of a treatment, such as US, ES, or exercise, we look at the whole picture. My clinic sees well over 300 visits per week, and that is with 14 other PT clinics within a 5-10 minute drive. Why? I have very good results, reported by previous patients, physicians, and payors. My utilization rates are extremely low, and my outcomes are excellent. There are many different facets to my performance, from my personal interactions with patients, ability to motivate patients, methods of applying treatment, etc. Perhaps I provide a treatment in such a way that a previous study indicating it's ineffectiveness becomes null and void!
One month ago I spoke with an orthpaedic surgeon about the two common methods of ACL reconstruction. I informed him that the physicians in my building utilize the hamstring graft with endobutton fixation. His replys was that this method has resulted in too much laxity. However, when I perform KT1000 testing, the knees are tight. I spoke to one of my surgeons and questioned him on the comments made by the other. His reply? Sometimes he alters the tibial screw, so that as he tightens it, the sutures anchor with more tension. Other times, he manually pre-stretches the graft prior to insertion. He mentioned 3 or 4 other techniques that he might use on a case by case basis. If the first surgeon performs a study that indicates the traditional method of endobutton fixation results in too much laxity, should the second physician cease to perform this technique? Of course not, but is he obligated to perform his own study to prove it's effectivenss? How can this be done, when he uses his skills and common sense to tweak things into success? How can a therapist with so many different nuances to his program prove that any one technique is significant? He cannot. However, he can look at the success of his clinic and his outcomes as proof that something is obviously working!
[QUOTE]Originally posted by Barrett:
“A growing number of healthcare practitioners advocate what they call ‘evidence’-based practice. It seems ironic that some advocates of this approach emphasize the usefulness of only one form of evidence: information gained from the statistical study of large groups of people. …If you want to know if a particular treatment works on the average, you need this kind of study. However, there is information that can never be gotten from doing this kind of research. Statistical studies will never tell you how a treatment works or how an individual functions, although it may suggest ideas. …Depending too much on group statistical methods thus promotes a generic approach…”
Bruce Kodish, Ph.D., P.T. in “Back Pain Solutions”
Yesterday I began to trudge through the latest edition of the PT Journal featuring the findings of the “Philadelphia Panel,” a group of clinicians, researchers and clinicians interested in neck, back, knee and shoulder pain. I have a lot left to read and maybe it’s not as bad as it seems to be just yet, but it appears that this group’s analysis of the evidence regarding the actual effect of many commonly used interventions is, well, non-existent. And I mean to a devastating degree. Take a look. Many of these procedures are steeped in tradition and locked into the protocols many departments established long ago.
What Kodish says above addresses this study to some degree but is probably insufficient to explain much of the success we seem (and I mean “seem”) to have doing things this panel has dismissed as having no effect.
For me personally the examination of many of these procedures is not relevant to my practice since I don’t do them anyway, but I know many fine therapists that do, and I’d like to know what they’re thinking in light of yesterday’s publication. [/QUOTE]
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Re: The Philadelphia Panel - October 17, 2001 3:43:00 AM
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mcap
Posts: 652
Joined: February 8, 2000
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Group:
I have not been able to read the Phili panel report yet but I will as soon as it is possible. A few thoughts......
SJSJSJSJSJSJ:
Sorry but I think you are off the mark with regard to RCTs. Like it or not, they are they gold standard of research presently. If you look at any of the task forces or the Cochrane reviews, they often don't consider studies that aren't randomized. And.....with no proof that many of these interventions work, there is not much of an ethical problem with providing a control. Take LBP for example. Any time anyone wants to do a high quality study, all they need do is compare a treatment group to an aerobic exercise group. Aerobic exercise has demonstrated excellent results in chronic patients.
With regards to the others......
I must agree with Drew. While I can see what Barrett and Update are saying, they are continuing down a dangerous path. Look.....everyone knows good research alone is only part of the picture. Power, influence, money, tradition will continue to drive practice patterns with or without reserach. And we all know that research can be twisted to benefit a group or intervention.
BUT......good randomized trials are still a necessity. Outcomes research and the beleif that you are helping are not enough. You may see good outcomes and even document them but there is no way to tell if your patients are benefiting from the placebo or even the Hawthorne effect.
Why should some insurance company pay soo much money simply to have the patient reassured by a P.T? That isn't our job. If a patient is given a diagnosis by a healthcare professional, then it is up to that professional to explain the implications and to reassure when necessary. Furthermore, how do you know that over the long run, your treatment and your reassurance don't contribute to the medicalization of the patient, fear avoidance behavior and dependance on healthcare guidance that might actually make the patient worse?
If you want to use the low back as an example, there is really no need to panic. But we may just have to accept that fact that at this point, nothing has been shown to have a long term effect when administered during the acute phase (although I think the australians did demonstrate some with seg stab). So what???? Do you know how many people get LBP each year. There is a 70-80% lifetime prevalance and I think something like a 50% yearly prevalance. 1 million permanent disabilities and 1 million temporary disabilities at any one given time. There is more than enough out there for us to treat for a very long time. Exercise is recommended in the subacute phase. If we had substantial evidence of efficacy of treatment even at this point, we would be fine. But we don't. And bemoaning the fact that we aren't getting many acute patients misses the point.
I personally feel that we don't have much of a role to play in acute LBP. Acute patients need careful screening, aggressive pain control and close follow-up. For those whose pain resolves in a few weeks, there probably is no more intervention needed. In sending patients to P.T., I think phyisicans often pass the buck on pain control to us who have far less powerful tools. It also keeps them from evaluating who is at risk for disability.
When patients are subacute and still experiencing symptoms and functional limitations, I think some of our interventions can be valuable and are worthy of reimbursement.
PTupdate, I agree with some of your points but there is a bottom line. Without more RCTs (designed well), there will be no reimbursement down the road. There is nothing you can do to change that.
Every time one of us points to the lack of evidence behind and intervention, there is criticism and a lot of defensive justification. It is time for us to confront the issue with some honesty and candor. Instead of stating why the research is hard to do or why we don't need it why don't we ask the real question. Is what I am doing truly working? Only then can we grow as a profession.
Just my 2 cents.....
mcap
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Re: The Philadelphia Panel - October 17, 2001 5:23:00 AM
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Andrew M. Ball MS MBA PT
Posts: 271
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From: Chapel Hill
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Mcap,
Great points. I agree completely, but feel I must add a few things . . .
FIRST: The Hawthorne Effect kicks! For those of you who don't know, it's also known as the Novelty Effect. It states that when patients are in treatment (or in experimental group), they may perform better, or experience symptom reduction simply as a result of doing something different than the norm. Clinicians are typically unable to determine what is Hawthorne Effect and what is their own clinical skill because typically, if the patient gets better, they don't care. RCT are not necessary (nor is it ethical to withhold treatment), but we should at the very least be doing ABAB studies, or comparison studies of one technique to another using matched subjects randomized to one group or the other. That's a relatively easy study to do, but most clinicians cop out of this type of clinical research too, perhaps due to a need to protect one's professional ego from the bruise of recognizing that they've quite possibly not really helped a single patient over the entire span of their professional career. I can certainly understand the ego defense, but our profession suffers by coddling the individual professional egos of the less scientifically competent/evidence-oriented ranks of physical therapy.
Furthermore, the John Henry Effect states that when people know that they are being watched, they tend to outperform their typical level of operation. That goes for patients in the experimental group, the control group, and the therapist himself/herself. As a result, the therapist, physician, lawyer, etc., usually has an inflated view of their own competence upon self-assessment.
Evidence of this can be seen in the research conducted in the mid-1970's on the ability of the MD to self-assess personal areas of clinical strength and weakness.
SECOND: I didn't say that PT has no business in acute back pain. We do, but not as clinicians . . . unless we're acting as clinical researchers that don't charge for the service. We SHOULD be collecting data on the characteristics of all individuals that come to the clinic with acute LBP. 80% of these folks will self-resolve within two weeks (which is why I'm not impressed with those PT's that claim that about 75% of their LBP pain patients get better - their outcomes are actually, by documented standards, substandard . . . even if they get better results than anyone else in the area).
Anyway, by collecting this data (and I mean exhaustive stuff like education level, SES, marital status, history of smoking, - anything that could be remotely related to LBP symtomology) and looking for qualitative trends, mabye we can identify, as early as the acute phase, WHICH OF THOSE PATIENTS ARE GOING TO END UP BEING ONE OF THE 20% THAT CONTINUE INTO THE CHRONIC PHASE!
I don't hear of anyone even trying to do that though . . . pity.
Drew
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Re: The Philadelphia Panel - October 17, 2001 9:50:00 AM
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mcap
Posts: 652
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SJSJSJSJSJSJSJSJSJSJSJSJSJSJSJSJSJ:
It always comes back to the horse, don't it????????
I agree with you but you should realize that RCTs do not require a no treatment group. You could have a well designed RCT that compares two different interventions. IE, McKenzie vs. aerobic exercise. Or Ultrasound vs. active exercise.
Your points about practice settings and productivity requirements are well taken.
I think the answer could lie within the programs. I think it would be better if more programs had faculty practices and if they were connected to medical centers. This would allow for more provider relationships and would provide an ideal setting for some of this clinical research. Of course, all of this still costs money and I don't where that is coming from.
Drew.....I agree with you totally. The Hawthorne effect goes unacknowledged by most PTs but it is well documented in business. You can't mention any kind of ergonomic intervention without someone pointing to it.
One cautionary note however.......many of the numbers indicating that X percentage of LBP patients will improve within X weeks are not correct. LBP is proving to be more of a continual, refractory problem than previously thought.....
Your ideas for LBP research, documenting characteristics and attempting to figure out who develops chronocity/disability are right on the money. I know some people who are working on this sort of thing........
mcap
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Re: The Philadelphia Panel - October 17, 2001 1:55:00 PM
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mcap
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SJSJSJSJSJSJSJSJSJ:
People are actually looking at those factors and trying to predict disability while still in the acute phase. So far no study has turned up anything conculsive. You can use the "yellow flags" from the New Zealand guidelines as a warning system. But as far as I understand, many of them don't appear until after the acute phase.
mcap
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Re: The Philadelphia Panel - October 20, 2001 7:41:00 AM
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sarty
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From: Florida, USA
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I've been following this thread with interest.
Here are a few thoughts that I have:
*I agree with the statement that acute LBP will resolve itself within 2 weeks in 80% of cases, even without any intervention; however, I would be in favor of a few PT visits during that phase....not under the guise of being necessary for recovery, but rather to identify and correct the causes of the symptoms, and make the patient independent in management of any future flare-ups: ergonomic assessments, posture education/body mechanics education, pain management techniques, stretches if applicable, or McKenzie techniques if applicable, etc. Theoretically, this would decrease the need for further medical intervention for that patient. So my point is that I think it is unwise to issue a blanket statement about the effectiveness of PT during the acute phase.
*My other thought on all of this was that my level of skill at applying a certain technique and another therapist's skill could be very different. In the RCTs (as I understand them), the application is standardized. I think that the standardization helps to show if the technique itself is effective; however, it does not take into account that PT #1 may have smaller hands, or PT #2 may have a more assertive personality, or PT #3 may have graduated 2 weeks ago and his hands shake when he mobilizes a joint. I think this will change not only the application of the technique from a technical stand-point, but also the effectiveness from a patient stand-point, meaning that the patient's perception and expectation plays a part in the result.
*Finally, every person's body, while anatomically very similar, is unique. What works on patient A, may not work on patient B. This may be because of psychological differences. It may be because of different body frames, differing metabolism, their medical history, medications they are taking, etc. I agree, a femur is a femur and a gastroc is a gastroc, but I believe that we cannot overlook are differences.
We all have different finger prints, and just because an RCT says that 99% of patients with X show no objective improvement with treatment Y, that doesn't mean that I won't, and it doesn't mean that third party payers should automatically deny funding for it.
This is where I have difficulty: how can I take the research findings and uniformly apply them, when I know that each therapist and each patient is unique?
You know, to be honest, I hesitate to hit the 'submit reply' button below. I am a PTA, and I often hesitate to reply to because those of you here with much higher degrees (and other PTAs here) are able to express your ideas so more succintly than I. I'm here because I learn so much from these discussions, but at the same time, I don't want my rambling attempts to express my thoughts and questions to interfere.
Jenny
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Re: The Philadelphia Panel - October 20, 2001 8:32:00 PM
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Andrew M. Ball MS MBA PT
Posts: 271
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From: Chapel Hill
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You raise a few great points Sarty:
First of all, I for one am glad that you spoke up during this discussion, you raised several points that a few of us missed! I can only speak for myself, but my extra degrees are in areas other than PT. When it comes to PT, we're equals . . . though I'll admit until people meet me in person, it does somehow make people a little more nervous to challenge any of my views.
Don't be shy. That's what this forum is for, and you rasied a few great points that some of us who have additional advanced degrees completely missed.
Specifically, we should examine the difference between standardization, and the rigidity/inflexibility of that standardization for the purposes of norm-referencing.
A research study is only made rigid to the point of the objective definitions of the study. Most pediatric PT's run into this idea when testing kids using formal tools. Standardization means that there is a specific way to administer the treatment or test item. The Peabody, for example, is very rigid with what can be said during the test item. If, for example, the kids in the norm-ref. group were simply told to, "walk up the steps," and you're telling the child your testing to "walk up the steps and get the toy," you're either giving the child an unfair advantage over the norm-ref group, or conversely, using too many words for the child you're testing to process. Either way, you've changed the parameters of the test item.
The AIMS and Batelle, on the other hand, are still both standardized and norm-referenced, but are far less rigid. All the AIMS asks for is that the kid be put in a position (e.g. prone) and watched for what they do. The Battelle is even less rigid as special accommodations can be made for specific disabled populations.
They're all still standardized and norm-referenced though.
It's the same with the Philly Panel. If the term "exercise" is used, leaving the PT to choose what he or she believes to be the best therex program for the patient . . . that mimics real life better than forcing a specific exercise technique upon the PT doesn't it? For the purposes of outcomes research, a less rigid standardization is sometimes actually preferable because it more accurately mimics what's going on in the clinic.
It's also still standardized (albeit not too specific). There may be techniques that work, but in practice, according to the Philly Panel, PT's aren't getting any effects from exercise in the acute phase when left to act as they would making clinical decisions in the clinical practice setting.
It's the same thing that happens when NDT trained therapists examine the NDT vs. PWBTT research. They always throw a fit about specific techniques not being defined and the research not being valid. My response is they don't get it. And I don't know how to get them to see it . . . it's not only valid, but it's worse than they think!
If therapists are given the latitude to use whatever NDT technique they want, but still show no effects in 3 weeks relative to dramatic effects seen with PWBTT during the same time span . . . that better mimics what's happening in the clinics than if a specific technique was imposed upon the clinicians in the research protocol.
Finally, I've found that though there are differences between patients, most people are much more alike than different. It's important to recognize individual differences . . . but it's also important not to use it as an excuse when clinical trials don't yield the results that we expect or want.
Drew
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Re: The Philadelphia Panel - October 22, 2001 8:50:00 AM
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mcap
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Sarty:
You raise excellent points and you should NEVER hesitate to post your opinion. There are discussions and disagreements but that is what scientific discussion is all about. I am refuted, strongly, by my faculty on a regular basis. Sometimes I even feel that they are stil in the wrong. But you don't take it personally. That is what higher study in science is all about.
As for your points....I would like to add a couple of things......
1. I would caution practicioners to look a little more closely at how quickly LBP patients recovery. This business of 80-90% within a few weeks is not accurate. Many of the research behind those clamis involves studies where they tracked who returned to the doctor. Some more recent work has discovered that patients weren't actually getting better - they just weren't going back to the doctor. So it is fair to say that most LBP patients make a full FUNCTIONAL recovery in 6 weeeks (back to work, etc.). But many of them experience consistent or recurring pain after.
2. Your point about standardization is a good one. For example, the way McKenzie is practiced by the Dipomates is far different than what is studied. In practice, a McKenzie expert, may determine someone has a SIJ problem and use stabilization, or they may feel that someone has a disc lesion that is inflamed and would benefit from an injection, they may add other treatments...etc. So the confines of study paramters limit their effectiveness. It is a problem with no easy answer because you need some uniformity of treatment to show effect.
However, in the literature, there are cases where the treating practicioner is given latitude to use multiple modalities. Again, they key here is to have a good control group. I have said it again and again with LBP. With aerobic exercise producing such good benefits.....you could ethically compare most treatments to it in a randomized trial.
As for manual technique I agree with your points as well. But this effect could be mitigated by having therapists with at least X year of experience and by having people who have been credentialed in the techniques they are applying. There are several high level manual therapy certifications out there. And....at least this would guarantee some minimal level of standards........
mcap
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