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Re: Lets review some literature.
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Re: Lets review some literature. - March 2, 2006 8:24:00 PM
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chico
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The study should have had some type of placebo, either by sham OMT and/or a sugar-pill. Dr. Wagner, do you perform any OMT in your ED?
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Re: Lets review some literature. - March 3, 2006 1:59:00 AM
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Dr.Wagner
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I'll try to address a few questions here.
For Clinical Research to be CLINICALLY USEFUL, the comparison needs to be useful. When comparing 2 modalities and looking at a question of "benefit" it is important to look at the gold standard in care (ie if looking at what decreases swelling immediately after injury, I think comparing something to ice or compression would be the 'gold standard').
Next, while I haven't presented ALL the methodology, Toradol 30 IM was compared. This is not the typical dose, 60mg IM is more of the standard. So does that still weaken the clinical standard of care comparison...likely.
To SJ's question.
I think the question and the study is VERY important. 1. It addresses acute pain and manipulation. 2. It is basic CLINICAL RESEARCH and looks at flaws in even MAJOR journals. 3. It provides critical thinking skills when looking at journals. MOST journal articles can be picked apart, this is good. If we make faulty assumptions on faulty literature, then it fogs our decision making skills. That is NOT to say even faulty literature doesn't have useful information, but allows us to understand it must be taken with a grain of salt. Most EBM physicians attempt to be critical reviewers of literature. This is NOT common in Family Practice, but it more common in Academic Centers and the Physicians that practice there.
Next question, "DO I PRACTICE OMT IN THE ED".
Well, the practice of OMT (osteopathic manipulative treatment) is more than "rack and crack". I give exercises, stretches and activity modification. I also refer to PT DAILY. Now, I wish I knew my PT's better, but I don't. But I think I practice OPP (osteopathic principles and practice) and less hands on therapy.
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Dr. Wagner DO
Moderator of Medical Complexity Forum
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Re: Lets review some literature. - March 3, 2006 2:07:00 AM
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SJBird55
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From: Michigan
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huh? If you were talking to me, I have no clue whatsoever what you meant in that paragraph.
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Re: Lets review some literature. - March 3, 2006 12:48:00 PM
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Dr.Wagner
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From: Indianapolis
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YO SJ, you said the article wasn't relevent...I was giving you a couple reasons why I think the article was relevent...thats all.
I don't do much OMT in the ED. Really not the best place for it.
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Dr. Wagner DO
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Re: Lets review some literature. - March 3, 2006 2:23:00 PM
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SJBird55
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From: Michigan
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Ah, now I got you. It still doesn't have any clinical relevancy to me. ;) (from a physical therapy perspective... I'm sure there is some relevancy, but nothing I'm going to use)
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Re: Lets review some literature. - March 4, 2006 3:01:00 AM
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Sean_Collins
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The only thing I would like to point out is that what is "Gold Standard" and "more of the standard" seems to be a point of disagreement between Dr. Wagner and the authors of this paper from which many of Dr. Wagners critical comments arise. However, as we all are aware, there is a difference between "known" gold standards of care and those that are "believed" to be the standard. This can vary between clinicians, hospitals, regions, etc..
Based on the above - is what you would consider the gold standard, or more of the standard, reported as a position paper of an authority in the field, or other such similar recognition as a gold standard of practice?
_____________________________
Sean M. Collins, PT, ScD, CCS
Associate Professor
Research Coordinator
Department of Physical Therapy
Coordinator, Graduate Program in Disability Outcomes
Adjunct Professor, Department of Work Environment
School of Health &
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Re: Lets review some literature. - March 4, 2006 4:36:00 AM
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Dr.Wagner
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Would really like to get past this point.
The "gold standard" does not shift. The gold standard is not the same as "standard of care" which can be somewhat different from institution to institution based upon facilities etc.
Next is the criticism of a LACK of placebo arm. This is a significant fault of the paper. When creating a paper on harm or benefit, placebo creates the baseline from which one can judge. (ie comparing 2 modalities doesn't do much when neither can out perform a placebo).
Next is the LACK of defined treatment in the OMT group. Each patient was essentially treated very differently. One person, soft tissue, the next muscle energy, the next HVLA, the next all of the above. This lack of standardized treatment is bothersome and likely shakes at the validity of the research...it cannot be reproduced.
Next, I think there can be considerable discussion as to why there was no "call back" of these patients. Following these patients as far as 8-12-24 hours post treatment allows a further benefit analysis. While I am curious as to reducing a patients pain in the ED, I would be very disappointed if they returned home only to feel "worse" or "no benefit" from the treatment they recieved.
I find this to be a major flaw, providing VERY LITTLE utility as a clinician. If treatment has no carryover into the home or work environment, it serves no purpose.
More to come
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Dr. Wagner DO
Moderator of Medical Complexity Forum
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Re: Lets review some literature. - March 9, 2006 6:59:00 AM
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Sean_Collins
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From: Massachusetts
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It is difficult to get past a point if the point is not clearly made. How would you define "gold standard?" And who decides what is the gold standard?
How would a placebo be implemented in a study on OMT? I am honestly just curious - do you touch them but not do anything therapeutic?
In terms of defined treatment - isn't a benefit of OMT that it varies between patients depending on what they need? If you provide the same defined OMT - doesnt that bias the study to the null?
I agree with you on the lack of follow up - that is a big problem. But it still does not reduce the ability of this study to demonstrate evidence of causation for reduced pain immediatly following treatment. This brings up another issue of course - are we critiquing this for assessment of its ability to support the purpose and conclusions of the authors? Or for "clinical utility?" If for clinical utility - and you start adding questions - like about follow up - then isnt it unfair to expect that to be addressed in a study when it was not the goal of that study?
_____________________________
Sean M. Collins, PT, ScD, CCS
Associate Professor
Research Coordinator
Department of Physical Therapy
Coordinator, Graduate Program in Disability Outcomes
Adjunct Professor, Department of Work Environment
School of Health &
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Re: Lets review some literature. - March 13, 2006 8:47:00 AM
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Zeke W.
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Good points, Sean. Hopefully DocWagner can address these issues.
Zeke
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Re: Lets review some literature. - March 14, 2006 3:24:00 PM
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Dr.Wagner
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From: Indianapolis
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Gold Standards are applied in Medicine. This is not typical of Physical Therapy (ie what is the typical first line therapy for back pain...depends on who you ask).
Gold Standards or DOC's are created by each specialty group IE the American Board of Emergency Medicine in conjunction with the College of Emergency Physicians etc. They are drawn by consensus.
Ie the Gold Standard Treatment for Acute MI is Stent Placement.
Next.
The Treatment NEEDS standardization primarily to make a fair comparison...there is no discussion of whether one patient recieved 15min of soft tissue or another recieved 5 minutes...Muscle energy vs HVLA. the term "OMT" is far too extensive. To even narrow the treatment to parameters including soft tissue and Muscle Energy only...name the technique at least! Without this small bit of detail there is ABSOLUTELY NO WAY this can be validated. None. So what does it ultimately prove?
This article is an attempt...but it falls short of any clinical relevence.
(PS we could take issue at the EXTENSIVE exclusion criteria as well...one would have to ask, if you select out only the PERFECT patient ...would that itself bias the results? YES)
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Dr. Wagner DO
Moderator of Medical Complexity Forum
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