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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 12:55:00 PM
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Jon Newman
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Hi SJ,
Glad you were able to improve your outcomes. I think your statement "put on my face of confidence" might very well be important regardless of what technique you're using. Why do you suppose that is? I would be willing to bet many people find that the new cont. ed. technique they learned 'really worked'.
I think we've established that this was a good study. I would love to hear peoples' thoughts on how manipulation works now. Especially that it also seems that there is some agreement that the biomechanical rationale is slipping away. I've given some of my thoughts already and I have others although they may just be deeper explorations of what I've already offered.
jon
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Re: Look at this validation study guys, worth reading! - January 13, 2005 1:25:00 PM
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Jon Newman
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I'm feeling "posty" tonight. Ok, even more than normal. Enjoy this link.
http://bmj.bmjjournals.com/cgi/content/full/bmj;329/7480/1447
jon
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Re: Look at this validation study guys, worth reading! - January 13, 2005 2:12:00 PM
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Jon Newman
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John C.
I've been to Barrett's course and I use what I've learned there, although most of that knowledge is offered for free on his website. Not exactly the strategy of a charlatan. I still feel that Simple Contact is more about approach and philosophy of patient care than it is about technique. The philosophy and approach is patient centered and promotes self efficacy. How can that be bad?
jon
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Re: Look at this validation study guys, worth reading! - January 13, 2005 3:07:00 PM
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ericm
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You are absolutely right Jon. I think our profession's role is best defined as clinicians, not technitions and Simple Contact provides a solid platform on which to base clinical decision making. I'd argue that everything Barrett teaches is available for free on his website.
I'm also reminded of the words of Nicolai Bogduk, who stated "absence of evidence is not evidence for absence."
eric
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Re: Look at this validation study guys, worth reading! - January 13, 2005 3:34:00 PM
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Jon Newman
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So I've been thinking about predictive factors of outcomes. I'm asking the following question on NOI but in a different context.
If you address the predicitve factors of an outcome, can you impact the outcome in a predictable manner? If the answer is yes, then:
In this study there is only one factor that we can and want to change that is a potential predictor of outcomes. That is the hypomobile segment at any level. This brings me to the following questions:
What makes that segment hypomobile?
What methods do we have to make it less so? Manipulation is likely one of them. I say likely because reassessing the hypomobile segment was not part of this study but I'm sure there is something out there to support that this occurs. Please feel free to offer references in support or against this notion.
What do you think?
jon
Eric, I'd like to add that technique is the manifestation of the construct that underpins it.
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Re: Look at this validation study guys, worth reading! - January 13, 2005 3:52:00 PM
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childsjd
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All:
Indeed, the absence of evidence is not evidence for absence. This statement could not be more true. But Barrett is holding up "Simple Contact" as an evidence-based strategy with "hard science" to support its effectiveness. The only thing I have asked is that this evidence be produced. It is no crime that it doesn't exist. The problem I have is that this approach is being marketed as something supported by "hard science", when none in fact exists.
By the way, I do not intend to question Barrett's motives. I have no idea (nor do I really care) about what financial interests are at stake. This is a larger credibility issue in terms of the responsibilities we have as professionals to differentiate between what evidence is, and what it is not. We have a long ways to go. The good news is that our transition to a doctoring profession and autonomous practice will invoke a gradual shift in expectations, inciting an awakening of sorts that offers much promise for the years ahead. The physical therapists of tomorrow will be less likley to become entranced by fanciful treatment paradigms (however well intended they may be) and more inclined to seek new knowledge from the peer-reviewed literature with the mindset of how best to translate this information into clinical practice so that it benefits the patient sitting in front of them.
John
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Re: Look at this validation study guys, worth reading! - January 13, 2005 4:08:00 PM
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Jon Newman
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Hi John,
Your statement, "The good news is that our transition to a doctoring profession and autonomous practice will invoke a gradual shift in expectations, inciting an awakening of sorts that offers much promise for the years ahead", reminded me, for some reason, of a quote by Laura Riding Jackson. Here it is:
"We shall know that we have begun to speak true by an increased hunger for true-speaking; we shall have the whole hunger only after we have given ourselves the first taste of it."
jon
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[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Look at this validation study guys, worth reading! - January 13, 2005 7:36:00 PM
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Alex Brenner PT MPT OCS
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You can't argue this study. It was well designed and conducted by some of the top researchers in our field. I wonder if it is the actual technique itself that is the reason that many are hesitant to try it, learn it, and incorporate it into their practice. If the intervention for this study was to gently pat the patient on the butt, would more try it? Barrett and others have described the technique as coercive. This is hogwash. As I have attempted to explain long in the past, the technique is easy to learn and perform, non coercive and is very effective.
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Alex Brenner, PT, MPT, OCS
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Re: Look at this validation study guys, worth reading! - January 13, 2005 10:48:00 PM
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nari
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John
I am not criticising your study, by the way.
What you might like to do sometime is read hundreds of references in the papers written by Shacklock, Wall, Butler, Moseley and others. They are there, on many sites such as PubMed.
It has not been called adverse neural tension for about ten years now...
Practising only with EBM as it stands at present -it is early days - would leave the profession very short on options. I don't think, at present we can afford to do that. We should not abandon techniques that are highly beneficial to patients because the jury is out on whether they are valid or not. Ultrasound is still widely used in the world, I am sure, though its usefulness above placebo effect has only been shown in a few studies.
Autonomy does not really guarantee highly selective, valid treatments. We have been autonomous for nearly thirty years- and although it is much valued, it does not necessarily promote critical, selective thinking and assessment techniques. That remains an individual choice for many PTs.
Nari
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Re: Look at this validation study guys, worth reading! - January 13, 2005 11:08:00 PM
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Randy Dixon
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I have found this to be an interesting thread. It highlights what in my observation is one of the emerging and, in some ways divisive, issues of the PT world. The interpretation of what is practicing in an evidence based manner. A parallel division is that of the influence of patient psychological issues and how they are dealt with in a clinical setting, with one camp believing that they lie outside the scope and concern of PT and the other camp feeling they are an intrinsic, integral part of the treatment process and should be further included in the scope of PT. I believe much of the uncomfortableness of the former group is the lack of easily quantifiable data and control when dealing with these issues which makes “hard science” very difficult.
The aspirin analogy was interesting in that Dr. Childs used it to make the point that aspirins efficacy was established long before the underlying mechanisms were understood, that it was discovered by accident, tested empirically and then proven scientifically. On the other hand, it’s efficacy was well accepted and it’s application well documented long before any controlled studies were conducted on it. I think some of the disagreement on this thread is that some took Dr. Childs challenge to present proof as an indictment against what they are doing, I don’t believe that was his intention. I think some of the confusion is cause by the difference between direct evidence and indirect evidence. In the aspirin case above, it was probably discovered by accident, but then proven with studies and so supported by direct evidence. Beta-blockers and statin drugs were discovered differently, (or so I believe, just play along) in their case the body of knowledge on physiology was used to construct a theory and then the drugs were designed to fit that model, I believe that is what the “bottom up” people are advocating, and I also think this is evidence based, although the evidence is indirect. This theory though must not only be viable and supportable but to maintain credibility it must be at some point subjected to controlled studies and tested, even with concerns about what exactly is being tested and measured. Until it is, then any statements about treatments derived from that theory should be prefaced, explicitly or implicitly, with something like “It is my belief”.
This was a good study, I already have seen it being referenced in articles and papers. The danger, as with any study, is in it’s interpretation, that things will be read into it that aren’t present. For those not using manipulation, it should, at least, cause you to reconsider with the pt. Population identified, if you have concerns about the evidence or the study you have the opportunity to address them here, that is a great opportunity you don’t usually get when reading a study. For those who believe that other techniques are more effective this study should be a motivator to conduct studies to show that. I think and I feel have their place in clinical decision making but they will, or should, always be trumped by proof.
Ancedotally, the only medical intervention that I have ever received that I felt did me any good, besides perhaps inoculations, was an adjustment by a chiropractor using the technique shown in the video. I don’t think he knew what he did, but it gave me instant, lasting relief. I still wonder about the difference between self adjustment and therapy provided and like Diane and some others I have seen “crack addicts” who need adjustments and who seem to have hypermobile segments and other problems seemingly as a result of many manipulations. I don’t think it is fair to ask Dr. Childs to defend this when it was not an issue to come up in the study.
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Re: Look at this validation study guys, worth reading! - January 13, 2005 11:44:00 PM
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childsjd
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Randy:
You make some insightful comments. To be clear, I am not here to "defend" my study. That's the value of publishing in the peer-reviewed literature. Its "defense" is inherent in the fact that it's published in one of the leading medical journals in the world, where over 90% of papers submitted for publication are rejected. Do not percieve this as boasting, because this is not the point (by the way, projects like this only happen because of the selfless efforts of many, the acknowledgement of which extends far past the list of authors). The case I am making is a much bigger issue than getting the folks in this forum to "agree" that our study offers compelling evidence. The point is that it is fascinating to watch so called skeptics argue with data, when they offer no compelling arguments to the contrary (ie, producing data themselves). Personal experience, textbooks (the medium in which personal experience often, although not always, masquerades as science), etc. are the lowest form of evidence on the evidence hierarchy for good reason. They are inherently fraught with bias. I like Sackett's recommendation that all textbooks be burned (including his he would recommend should you give it more weight that it deserves).
I recognize there are papers published by some of the names mentioned previously by Barrett. I am not here to denigrate their work. It's just that controlled trials don't exist taking these theoretical constructs and applying them to real patients with real pain. There is nothing wrong with pondering new ideas and trying to help patients with innovative treatment approaches. However, until evidence exists to support them, we must be highly skeptical of those who hold up these treatment paradigms as being superior to other treatment approaches that have been subjected to rigorous scientific study. Arguments about what works "in my hands" should mostly fall on deaf ears unless there is nothing the peer-reviewed literature has to offer. However, there is enough good evidence now to support much of what we do in physical therapy practice (not just manipulation) that our time and effort is better spent learning to apply the evidence that does exist rather than being enamored by compelling stories about what has worked for an entrpreneurial individual practitioner who is persuasive with language, but who has little foundation upon which to base his position. This is not an attack on Barrett per se. The list of individuals out on the continuing education circuit perpetuating similar myths and half truths (however well intended) extends well past the individual at whom my criticism is directed here. The good news, for reasons previously outlined, is that times "they are a changin'".
John
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Re: Look at this validation study guys, worth reading! - January 14, 2005 12:09:00 AM
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Andrew M. Ball PT PhD
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Jon,
Let's get back to the topic at hand. The CPR for identification of patients who will benefit from spinal manipulation is a great step forward for our profession and you are to be congratulated.
My concern is how the study will be over-generalized over the next few years. The CPR will apply to but a handful of patients that we see --- especially those PT's not working (as you do in the army) in a stricly direct access primary portal role. Your article states that, if 4 out of 5 criteria are met, a patient has a 92% chance of successful therapeutic outcome if treated by manipulation. We should note, however, that your study also states that spinal manipulation plus exercise produced outcomes for LBP similar to those produced by exercise alone.
While it is true that some patients did respond to spinal manipulation only, the clinical prediction and that the rule is designed to identify such patients --- I doubt that manipulation-only approaches will be used in the clinic as therex is generally easy to justify, can be easily delegated, and increases revenue. Finally, your study did not look at repeat injury beyond 6 months, and it could be suggested that the manipulation only group had a higher rate of subesquent return to injury due to lack of lumbar stabilization and/or neutral spine training. The only flaw that I saw with the study, is that this fact was not fully defined in the limitations section of the study --- and that the study is higly likely to be used out of context as it makes its way to use in the clinic.
As someone with a nearly complete post-professional DPT and a PhD in Healthcare Management, my thoughts for future research lean toward the economic. If, for example, we're running a clinic supported by HMO's, the CPR for LBP could be a higly efficient tool --- assuming that we know that the rate of recurrence is x. Even with what is likely to be a higher recurrence rate, the cost of manipulation-only care may be so low so as to allow for a very high rate of patient injury recurrence before reaching an economic break-even point.
Jon, if you guys are considering publishing again, I offer my services for collaboration in that regard. I can be reached privately at DrDrewpt@msn.com or I'll give you my cell phone number if you'd like to talk through a few ideas.
Drew
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Dr. Andrew M. Ball, PT, DPT, Ph.D.
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Re: Look at this validation study guys, worth reading! - January 14, 2005 3:50:00 AM
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childsjd
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Drew:
I appreciate the comments, but you make several factual errors in your interpretation of the study. First, the study does not support the notion that manipulation is all these patients need (nor is that our intent or the conclsion in the study). Patients in the manipulation group recieved manipulation and a ROM exercise during week 1, but then completed a lumbar stabilization program without further manipulation for the remainder of the study. The only difference between the treatment groups was during week 1, when patients in the manipulation group received the manipulation. In other words, all patients who received manipulation also recieved the exercise strenghtening program (for the reasons you outline as a potential criticism of the study).
Secondly, although we have direct access privileges in the military, most of our business consists of patients referred from primary care or other specialists. All patients in this study were referred to PT.
Third, the outcomes from spinal manipulation plus exercise are only similar to exercise alone when you don't consider the patient's status on the prediction rule (and even when you ignore the rule, patients in the manip group experienced significantly improved disability and pain, albeit by a more clinically trivial amount). Patients who are positive on the rule and received the manipulation experienced substantial (about 70% greater on average!) improvement compared to patients who are positive on the rule and recieve exercise alone and compared to patients who are negative on the rule and recieve manipulation. That's the whole point of the study -- We need to identify patients who are positive on the rule and make sure we include manipulation as part of their treatment plan, lest someone else can demonstrate with evidence a treatment with the possibility of generating 50% improvements in disability on the Oswestry in such a short period of time.
Finally, 35% of patients with back pain met at least 4/5 criteria, roughly one-third. One-third of the vast number of patients with back pain that we see in physical therapy is not an insignificant and small number.
If anyone is not clear on what we did, please read the study. All of this is clear in the paper.
John
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Re: Look at this validation study guys, worth reading! - January 14, 2005 4:01:00 AM
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childsjd
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Nari:
Just to address this statement you make:
"Practising only with EBM as it stands at present -it is early days - would leave the profession very short on options. I don't think, at present we can afford to do that."
Yes, many questions remain, but for patients with back and neck pain in particular, we have lots of evidence to guide our decision-making. I do not mean this disrespectfully, but anyone who suggests that little evidence exists to support physical therapy practice for these patients is (in my opinion) just not informed or keeping up with the evidence.
John
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Re: Look at this validation study guys, worth reading! - January 14, 2005 4:06:00 AM
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childsjd
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Nari:
One other statement you make:
"We should not abandon techniques that are highly beneficial to patients because the jury is out on whether they are valid or not. Ultrasound is still widely used in the world, I am sure, though its usefulness above placebo effect has only been shown in a few studies."
Please show me the evidence you state exists for the techniques you know to be "highly beneficial". Experience "in your hands" is not evidence.
Also, the evidence for ultrasound is conclusive. It has been repeatedly shown to be ineffective for almost every musuloskeletal condition known to mankind except for bicipital tendinitis (and even then requires numerous treatments), yet why we repeatedly wave this wand over people is beyond me.
John
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Re: Look at this validation study guys, worth reading! - January 14, 2005 5:59:00 AM
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Jon Newman
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John,
I'm confused by your "in your hands" statement. Are you stating that clinical experience is not part of evidence based medicine? I thought EBM was clinical decision making at the intersection of evidence, clinical experience and values.
jon
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Re: Look at this validation study guys, worth reading! - January 14, 2005 6:25:00 AM
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OrthoSam
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Hi John,
I enjoyed ready your study and congratulate you on publication in such a fine peer reviewed journal! I am thankful that it was published in an internal medicine journal to assist appropriate early primary referrals to PT, based on evidence.
I have one question. In the inclusion criteria for treatment of manipulation, the patient has to have at least one hip with more than 35 degrees hip internal rotation. Can you explain that inclusion for me?
Thankyou,
Sam
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Re: Look at this validation study guys, worth reading! - January 14, 2005 6:49:00 AM
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childsjd
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Jon:
I am not suggesting that clinical experience is not helpful. However, clinical experience does not stand alone as evidence. Many practitioners will suggest that a particular treatment works "in my hands". That which is "felt" or "known" by one set of hands but cannot be reliably reproduced by another set of hands is at a very low level on the evidence hierarchy, presuming it should even be there at all. I am not, however, discounting the value of one's experience in applying high quality evidence within the context of the patient's values.
By the way, my impression is that we throw around this "patient values" idea as if this gives us the freedom to do whatever fringe treatment we want, or that the patient thinks will make them happy. I'm afraid we often hide behind our "patient's values" out of fear that we don't really understand how to provide evidence-based care. The reality I suspect is that we run into very few patients whose "values" genuinely conflict with optimal care based on the evidence.
John
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Re: Look at this validation study guys, worth reading! - January 14, 2005 6:53:00 AM
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childsjd
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Sam:
I understand your question, but to be clear, having more than 35 degrees of hip internal rotation ROM was not an inclusion criterion for the study. This is just one of the factors in the prediction rule.
Your guess is as good as mine as to why this factor emerged as prognostic. Pure speculation here (ie, being clear that what I am about to say does not constitute any resemblance of evidence), but perhaps having increased hip motion is a compensatory strategy for having a stiff lower back, presumably what we think we're treating with manipulation. The real answer lies somewhere in future research. Good question though.
John
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