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Re: Look at this validation study guys, worth reading!
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Re: Look at this validation study guys, worth reading! - January 13, 2005 2:57:00 AM
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childsjd
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Jon:
Regarding one of your previsous posts, we did not compare manipulation versus pelvic tilts and walking. The manip group was compared against a legitimate and compelling exercise strengthening program, making the conclusion recommending manipulation for at least this subgroup of patients that much more compelling.
John
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Re: Look at this validation study guys, worth reading! - January 13, 2005 5:01:00 AM
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Jon Newman
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Hi John,
Sorry for characterizing the non-manipulation group as "walking and pelvic tilts". What was it that this group actually did? I didn't quite get it from the article. I'll check the references for the description of these exercises when I get a chance.
I think you are mistaken in thinking that my argument is that one must fully understand why it is they are doing what they are doing before they do it. But it certainly helps. My point is that while you provide good evidence that manipulation works better than a particular treatment that also has good evidence, it does not mean that we cannont look at the ingredients that make it more effective.
The aspirin analogy is interesting. They didn't try to prove that it worked for 100's of years. They already figured that out. They instead focused on how it worked. And we are able to make better clinical decisions because of that. It sounds like you are arguing that I shouldn't be worried about why, just do as the experts suggest.
Perhaps, at one time, people had to eat the bark and the wood in its natural state. But later they figured out they just had to eat the bark. Then later they figured out they just had to boil the bark. Asking why is critical and your dimissive attitude about it is suprising to hear from a scientist. Do you have a political agenda that is diverting you from searching for the truth? Would you rather have us just eat the whole tree?
jon
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Look at this validation study guys, worth reading! - January 13, 2005 5:15:00 AM
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childsjd
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Your point is well taken. I completely agree that an understanding of mechanisims is important and may help generate new innovative treatment approaches. The point I am trying to make is that the absence of this information should not stand in the way of our making decisions about taking care of individual patients based on evidence from high quality clinical trials, despite not not full understanding the answers to the "why" questions.
I hear some on this forum suggesting that you have to start with this "bottom-up" approach before being able to make recommendations about what works and what doesn't this is the nonsense that I am referring to. The history of medicine suggests we almost always figure out the "what" prior to the "why", which is a good thing for patients who just want their pain and disability to go away.
Patients in the exercise group (and patients in the manip group after the first week) completed a lumbar stabilization exercise program based on some of O'Sullivan's and Hides' work and an aerobic exercise program.
John
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Re: Look at this validation study guys, worth reading! - January 13, 2005 6:04:00 AM
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Diane
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John,
(Maybe I should address you as "Major" John..) I expect your sample is young, uberfit and mostly mesomorphic. Am I right? Are they all gainfully employed by the air force in Texas? Disciplined and ready to receive orders at all times from superiors?
I am asking with my tongue stuck in my cheek a little. If this is true, that you studied a population that is that distinct from the general population, socially and physically, I doubt I'll ever have to select out such individuals from my own patient population to send your way so that they can receive "optimal" manipulation from you. I will be continuing, until I die probably, to adapt my own therapeutic self to the selves of my patients (a very motley crew indeed, completely unclassifiable) and treat them as optimally as I can. Most of them have already tried manipulation (from someone else) and it didn't work. To each their own. Meanwhile, I thank you and congratulate you for researching and publishing. But no higher horses for that, please.
That's it from me. Over and out.
Sub-optimally yours, and very civilian,
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Re: Look at this validation study guys, worth reading! - January 13, 2005 6:04:00 AM
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Barrett
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John
Well, John, now I see where you’re coming from. Somehow you have decided to lump me in with the snake oil salesmen who populate the landscape of continuing ed-people I have written about extensively and continue to publicly criticize for their lack of thoughtfulness or attention to the scientific method. I’m no fan of alternative medicine as anyone actually familiar with my work, writing or teaching will readily tell you, but perhaps your lack of familiarity is the problem. If you have any actual knowledge of what it is I personally do or say I’d like to know where you might have obtained that. Hundreds of essays are available for you to choose from for your criticism.
I wasn’t talking about the minor soreness that might result from manipulation. I guess what I described hasn’t happened to you, but I suspect that there are others reading this who recognize the situation. Your tendency to dismiss clinical experience as little more than a hallucination of some sort might make you skeptical of their (or my) experience, but skepticism is a method, not a position, and a method I am a big fan of. I am to my knowledge the only PT ever mentioned in “The Skeptical Inquirer” (favorably, I might add) and when you go to “The Skeptic’s Dictionary” on the web the sponsor recommends my writing. These guys are even more doubtful than you of any theory or practice. Of course this isn’t peer reviewed literature, but nothing gets in there that wouldn’t pass inspection by the same people who do such reviewing.
It seems the so-called neurobiologic revolution has escaped your notice; at least that would explain your lack of familiarity with any of the men I mentioned, among them researchers, clinicians and theorists who have published extensively in the literature we all value quite highly. Saying they have “infrequently” done so is simply untrue. When I hold aloft Butler’s text and read how he justifies his clinical examination (and mine) and treatment by citing the peer-reviewed studies of Sunderland and Elvey aren’t I teaching from an evidence-based framework? This work is neither “esoteric nor fanciful,” and I presume these authors and clinicians would agree with me there. I begin by speaking of the insights of Patrick Wall, possibly the most highly regarded neuroscientist, clinician and expert on pain of the twentieth century, and how what he tells us about human response to painful sensation must include instinctive movement not possibly achieved in any other way. I proceed clinically with what he says in mind. Why isn’t this acceptable?
You’re right, we don’t all have to do research that appears in pub med in order to do reasonable work, neither do we all have to be researchers to treat and teach. I am grateful for that.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Look at this validation study guys, worth reading! - January 13, 2005 6:38:00 AM
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atexanpt
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Earlier in the postings there were several requests for course listings. Dr. Childs is being gentlemanly (and rightfully so) and not posting his own site... [URL=http://www.evidenceinmotion.com.]www.evidenceinmotion.com.[/URL] I'm less gentlemanly so I'll point you to my own course as well at heassociates.org.
This technique is not difficult to learn, is firmly entrenched in evidence demonstrating its effectiveness and can dramatically improve results in many patients. It can be incorporated into nearly any other "system" of manual therapy because it is not dependent upon physical examination findings of questionable reliability.
On another note I think it worthwhile to note that the author's of the original study (Dr. Flynn, Whitmann, Wainner, etc.) as well as most of the data collectors, etc. for the validation study are all osteopathically trained manual therapists who have moved away from the more rigid biomechanical model- not folks who are simply scared away by talk of FRS(L) and R on L sacral torsions, etc.
_____________________________
David Browder, DPT, MS, OCS
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Re: Look at this validation study guys, worth reading! - January 13, 2005 6:55:00 AM
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Diane
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[QUOTE]not folks who are simply scared away by talk of FRS(L) and R on L sacral torsions, etc.[/QUOTE]Aaaaaah... I understand this language. Is this very adaptable and useful and benign system of assessment and segmental contract relax being included under the umbrella term "manipulation"? If so, I'm back on track in a big way. Maybe even something approaching "optimal"..
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Re: Look at this validation study guys, worth reading! - January 13, 2005 7:21:00 AM
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childsjd
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Barrett:
You perception of what constitutes evidence-based practice is far removed from what David Sackett was referring to when this term became in vogue. Essays and textbooks that may happen to have some peer-reviewed literature in the reference list does not constitute evidence, and implying that is does bastardizes the term itself.
In referring to the Skeptical Inquirer publication in which you are so "esteemly" quoted, you say the following:
"These guys are even more doubtful than you of any theory or practice. Of course this isn’t peer reviewed literature, but nothing gets in there that wouldn’t pass inspection by the same people who do such reviewing."
If you weren't so serious, such a statement would be hysterical. I'm afraid though that it reflects the reality of a misguided paradigm about what evidence-based practice is all about. I continue to ask that you cite here in this forum the literature that demonstrates your approach to be effective. You cannot do it because it doesn't exist. By the way, I continue to re-iterate that we certainly don't have all the answers. Theoretically, some of the concepts you espouse could eventually be supported with some level of evidence. My issue is the level of credence you attach to esoteric theories that have never been substantiated in a study involving real patients who have real pain. Basing our decision-making on the "best available evidence" means that we should look to the peer-reviewed literature to guide our decision-making, not essays, textbooks, and unsubstantiated theories.
I can't speak to your motives. You are likely a very cordial individual with whom I would enjoy associating. My criticism is in your holding up what you do as being evidence-based. As our profession continues to shift towards autonomous practice and a doctoring profession, I hope you are prepared for what will be a dramatic decrease in the tolerance and demand for the type of "education" that you proliferate amongst well-intended individuals searching for the yet non-existent holy grail for treating chronic pain.
John
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Re: Look at this validation study guys, worth reading! - January 13, 2005 8:51:00 AM
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Barrett
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John,
You say, "You are likely a very cordial individual with whom I would enjoy associating."
Knowing myself, I'm not so sure.
Okay,if EBM is, as you say, a narrowly defined method of practice and, if I adhere to your definition, I cannot say that I practice in this manner. Nor can I say I have an outcome study for you. I struggle with these things-Ceteris Peribus and all that, especially since what the decade of the brain taught us about "real people with real pain" (as opposed to those I see, I guess). In fact, I make no claims about outcomes, just ask my students. I only claim to make sensible clinical decisions given what we've learned about the body in pain. Or, at least, what I've read about that.
But Laurita Hack, the director of the program at Temple, specifically took issue with this narrow definition at the Prestige Day banquet at Cleveland State University in October 2003, stating that "evidence-based" includes an approach to care as much as proof of its efficacy, and that, at minimum, "outcome studies are not for the faint of heart." Your problem with this might be taken up with Dr. Hack. I contend that peer-reviewed literature that "guides my decision making" appropriately is essential to my approach, and your dismissal of it because it forms a portion of a textbook or is contained as a footnote to theory makes it worth no less.
When you say "textbooks that may happen to have some" peer-reviewed literature as the basis for the theory or practice makes me wonder about something. If Butler or Shacklock point out that Sunderland's and Elvey's (and others) peer-reviewed studies indicate something about nervous irritation, say for instance its tendency to produce symptoms in the absence of pathology, would explain the patient's complaint and findings, and I use his textbook to learn this, exactly at what point did this reasoning diverge from an examination of the peer-reviewed literature? When it was cited in a book? When I read it there? When Butler failed the polygraph?
I don't know where you get this "holy grail" reference. I've never, never offered such a thing, but, it seems as yet that you don't actually know what it is I teach.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Look at this validation study guys, worth reading! - January 13, 2005 9:48:00 AM
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nari
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Interesting discussion so far.
Manipulation seems to work,from various studies done over the last few years. It fails completely in other studies. So the decision to manipulate or not, is crucial, and based on extensive assessment. Also there is subtle pressure on PTs to learn or keep on manipulating, perhaps because the chiros do it.
No-one, to my knowledge, knows why it works when it does work. No-one can effectively explain why passive vertebral mobilisations work. Creating a bit of extra ROM does not necessarily resolve pain; there is a lot more to it.
I am with Barrett and Diane on this debate. There is strong evidence from the researchers whom Barrett mentions that neurodynamic techniques work, and the nice thing about neurodynamic work is that it does not create dependence- the patient can perform them out of the PT's rooms.
It empowers the patient, and that is important.
Patients can crack their own necks and backs and fingers and shoulders, but the effect seems fairly shortlived.
There is a place for manips. I won't deny that.
I would also say that not delivering appropriate neural techniques in a patient with isolated or composite pain, is delivering substandard treatment.
Preferences in the treatment selection is entirely dependent on the PT's knowledge and understanding of the many techniques available.
My $0.4 worth
Nari
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Re: Look at this validation study guys, worth reading! - January 13, 2005 9:54:00 AM
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steve
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You know what I find most interesting here is the skeptical response to this study. Dr. Childs and his fellow researchers essentialy are operating from the same stand point as many of you - he thought to himself "Hey this treatment (In this case manipulation) really is helpful". Then he took it a step further and created a well thought out research design and proved that it works and provided a set of specific criteria to when it will work and exactly what technique to use. With this intervention I can expect a 50% decrease in pain and disbility in 92% of my patients that meet the criteria. Easily reproducible in a clinical setting.
Explain to me why someone wouldn't use this intervention with someone who meets the criteria, irrespective of what my paradigm is with respect to how their clinical world works.
Steve
Barrett - I dont think you and Dr. Childs are that far apart in your thinking, just your terminology. From my limited exposure to your previous posts you focus on a very pain/central nervous system approach. Dr. Childs identifies these individuals as being not appropriate for this intervention based on a high fear avoidance belief.
PS having stated the above query to this forum, I am glad to see so many individuals posting about varying beliefs and paradigms - this is how new ideas and learning are developed.
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Re: Look at this validation study guys, worth reading! - January 13, 2005 10:11:00 AM
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childsjd
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Barrett:
To be as specific as possible, it is the "hard science" you refer to on your website (see the exact quote below) that I would be interested in knowing.
"I want to introduce you to literature that supports my interpretation of what we see and hear in the clinic and, most importantly, convince you with hard science that Simple Contact is a reasonable, safe and effective method of manual care."
Some resemblance of a RCT should be out there should we be compelled by the position you take. Until then, your skepticism imprisons you to your own fantasy world of "Simple Contact".
John
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Re: Look at this validation study guys, worth reading! - January 13, 2005 10:18:00 AM
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childsjd
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Barrett:
The err in your thinking is captured best by this statement:
"I make no claims about outcomes, just ask my students. I only claim to make sensible clinical decisions given what we've learned about the body in pain."
Outcomes is the only thing we should primarily be interested in. Patients want to get better, not be mesmerized by your personal affect. This is America, where you fortunately have the freedom of teaching whatever you wish. However, if your so-called sensible decisions do not generate an outcome greater than some other compelling alternative, it is disingenuous (and reckless as a licensed health care professional) to hold out what you do as being evidence-based.
John
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Re: Look at this validation study guys, worth reading! - January 13, 2005 10:23:00 AM
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childsjd
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Steve:
You continue to make sensible and rational arguments here, albeit it you are in the minority here.
John
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Re: Look at this validation study guys, worth reading! - January 13, 2005 10:38:00 AM
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childsjd
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Nari:
Like Barrett, I would ask you to show me the "strong evidence...that neurodynamic techniques work". I am not suggesting here that utilizing the concepts of adverse neural tension in your clinical practice is synonomous with quackery. In all likelihood, there may be a subset of patients in which some of these techniques are quite appropriate. It's just that you can't run around espousing all the evidence for the effectiveness of this approach. This evidence simply does not exist!
John
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Re: Look at this validation study guys, worth reading! - January 13, 2005 10:52:00 AM
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Barrett
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John,
So, I'm not just ignorant, I'm "reckless," "disingenuous," and "mezmorizing."
And all this time I had thought that this was simply going to be a discussion about EBM.
Guess not.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Look at this validation study guys, worth reading! - January 13, 2005 12:10:00 PM
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Jon Newman
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Hi Steve,
The reason I haven't been manipulating patients that have the characteristics of this population is that I have been having good outcomes with what I am doing. If someone is struggling with this population they really should consider manipulation over whatever it is they are doing. Or do some deeper thinking about why they aren't getting outcomes.
One could reasonably ask if I get a 92% success rate with this population but I couldn't honestly say. It would take me quite a while, with the diverse patient population that I see, to get a similar N of the population that fits that rule. And I don't trust most people's account of their personal performance over time, including mine. Although my personal trend has been for the better.
I'm inspired now to try to capture those statistics, it would be interesting. If it seems I'm failing, it would be wrong of me to continue to do what I'm doing in light of this evidence. I don't think it would be wrong of me not to drop what I'm doing in light of this evidence.
jon
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Look at this validation study guys, worth reading! - January 13, 2005 12:24:00 PM
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SJBird55
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Barrett, I've told you the same thing about what you do... I know you believe in what you do. I know that you've seen results with your approach. Maybe the generational (age) difference is a factor between some of us as professionals. But, I still can't understand why you just don't do some simple outcome study. I say simple, it may take a couple of years to complete, but why aren't you motivated in actually publishing something. Without taking your belief/philosophy and approach to the next step you probably aren't every going to have a leg to stand on.
John, I have read Wall's stuff and Shacklock and Sunderland. The problem with what I have read is that it hasn't floated down to the PT clinic level yet. It wasn't something that I could just put into use with patients... but it was interesting in the sense that I could grasp different theories of pain.
Just because evidence doesn't exist never equates to a process/procedure/approach not being beneficial or effective. I would hope, certainly hope, that let's say someone did try to provide evidence that an approach WAS effective, but found out the complete opposite that the person would have the courage to publish those findings too no matter how strongly the person believed in the approach. And also in the big picture and whatever politics are involved with accepting articles for publication that those types of findings are published also.
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Re: Look at this validation study guys, worth reading! - January 13, 2005 12:26:00 PM
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Jon Newman
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Hi Barvocosta,
You posed some questions that went unanswered on page 2 of this thread. In PT journal (Feb 84(2) 2004) Childs, et. al. state: "The evidence regarding exercise interventions for patients with LBP has been equivocal. Exercise has generally been reported to be ineffective for patients with acute LBP but is usually recommended for patients with chronic LBP."
This does not take away from the fact that the prediction rule was repeated and validated. And that was the point of the study. It was never meant to state that manipulation was better than another treatment (except the spinal stabilization exercise it was pitted against).
John C.: I couldn't find the O'sullivan Hides reference but did find this: Hides, Jull, Richardson, Long-term effects of specific stabilizing exercises for first episode low back pain. Spine, vol 26(11), June 2001 ppe243-e248. Is this the work you were referring too?
I should mention, in my previous post, that I use the RMQ more now than the oswestry for a variety of reasons. And I don't typically administer the actual written FABQ but verbally ask or ascertain from the patient's narrative the presence of these issues. If I feel the need to justify a change in treatment with a written test I wouldn't hesitate to use it but most of the time it seems it would be academic.
jon
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Look at this validation study guys, worth reading! - January 13, 2005 12:38:00 PM
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SJBird55
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Jon, your last point there is right on. Somehow or another we as physical therapists should be responsible for knowing our actual outcomes... otherwise how the heck do we make decisions on changing our practice patterns? How do we ever improve? We always assume that if we go to some continuing ed course that we're going to be that much better as therapists... but are we? Do we track our outcomes to then see/observe if we do become better clinicians with new knowledge gained? And, exactly... if I'm already getting the same outcomes but I'm doing something different, why the heck change? I'm already comfortable with my current approach and my current approach is adequate, even in light of new evidence in regard to a different type of approach.
I don't think that we as professionals as a whole actually put that responsibility on ourselves and value that kind of information enough.
Hey, I'm going to be the first to admit it. No, I was never trained in manipulations. That wasn't even offered in grad school. I do know my outcomes and I can tell you my discharge range is guesstimated on average about, I think 9 or 10 visits with an average disability of 20% or so. That isn't for just that specific population, but for all the patients with back pain without radicular symptoms lumped together. That study was a good study. John, you guys did a good job (and I know you know that). And, I'm not one to argue with numbers too much - everything made clinical sense... that graph of disability was very clear that there is a definite difference. So, hey, I suck at treating patients with back pain. I now have a goal of 5-8 visits and 10% disability with patients that fit the rule. And, you know what? Yep, I watched that little video and saw how the manipulation was done... I had a patient 2 weeks ago that fit the rule... took a deep breath, put on my face of confidence and did what the evidence said. Well, guess what... she came in with a 56% disability and was discharged after 5 visits with a 10% disability. I only did the manipulation once... no, she didn't have any additional soreness (but, well, I also cheat and believe in using a cold pack after because most patients that I do muscle energy on complain of an aching/bruised feeling so I found that if I do that no one ever complains to me). So, yeah, I did my own little thing, but it worked. Will I continue to use the technique? Sure.. for the right patient population. Why not? If there's a better, quicker, more efficient way, I'm all for it.
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