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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 15, 2005 6:24:00 PM
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Andrew M. Ball PT PhD
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From: Charlotte, NC
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Jon,
Don't get so defensive. I'm just asking. I agree that APTA membership is a large part of the answer. Having written my dissertation on the subject of joining behaviors of health professionals (or more to the point of this discussion, lack thereof of PT's in the APTA), and having given a few presentations at headquarters, I don't really think that anyone's in the position to lecture me about the value of APTA membership. I assume, therefore, that you're speaking to the vast numbers of PT's on this site that are not involved --- and support you in that charge.
Drew
_____________________________
Dr. Andrew M. Ball, PT, DPT, Ph.D.
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Re: Look at this validation study guys, worth reading! - January 15, 2005 10:49:00 PM
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michaelshacklock
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From: Adelaide, South Australiia
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Introducing myself, a newcomer to this discussion. My interest has of late been the neural events related to physical therapy. What I can observe from this conversation from a significant number of people participating (who clearly represent an even larger number of therapists and scientists) is that there are hugely different points of view. Scientific evidence is naturally a gold standard to adhere to. However, it is simply impossible at this stage to measure and prove everything and ideas must come from somewhere. My feeling about where they must come from is that they should both emerge from the laboratory and clinic. A major concern is that of one group of people saying that their echelon is the gold standard and others should be quiet. Many of the world's most innovative and successful solutions have come from people who did not undergo formal university training which at times is elitist and discriminatory, to the detriment of our patients. Hence, there must exist groups of people who do different things in the community for the common good. It is unfair of any representative of any particular group to say that another group's point of view is of little value because everyone actually helps in some way. I am a great fan of peer-reviewed literature and am regularly invited to review submissions for international peer-reviewed journals. I supervise research at the local university and I am also on the international adivsory board of one of the more notable peer-reviewed journals. This is because my contribution appears to be of value to our professional community which has taken it upon itself to help people with pain related to the musculoskeletal system. Although I have a master's degree, I have no PhD, nor am I a professor at a university. But why am I asked by scientists about my opinion and why can I walk into the local university and execute experiments with the professor of physiology? Once again, because my contribution is of value to the local professor who fortunately has an open mind in spite of being a basic scientist. So we should all be welcome in the team, even those who appear to not fit our personal notion what is right or wrong. We should never let science get in the way of a good idea. That is my political commment. The second aspect of my submission here is that a significant problem with the discussion is that those commenting often haven't read the literature or given detailed thought to their detractor's point of view. There is an enormous amount of evidence for the pain paradigm which is too expansive to present here. If detractors of the pain paradigm actually read the literature in detail, they would have to have their blinkers on to not take it seriously. It is up to the proponents of the pain sciences to present their rationale well and for those who receive it to appraise it critically BUT FAIRLY. There is also massive evidence for the peripheralist approach in musculoskeletal therapy. The two approaches are not mutually exclusive and should really work together. The third aspect of my submission is to ask what exactly about the neural aspect of musculoskeletal problems do therapists not understand? I ask this because I have just written a book about this subject which is to be released in the next couple of months by Elsevier Health and in it is a full explanation of much of the evidence for the neuromechanical approach (Clinical Neurodynamics: a new system of musculoskeletal treatment) and how to actually assess and treat through this modality as scientifically as possible. I say this last bit because therapists have so little knowledge of the area that they really are missing out an what is in some patients an important part of their problem. True, it will not be effective for everyone, but it is still a modality of treatment that has at times in the peer-reviewed literature, if you will, been shown to be effective. Lastly, some of the following key statements are well proven 1. Diagnostic efficacy for neural tests can reach 93% in carpal tunnel syndrome sufferers (ie. positive predictive power, sensitivity and specificity above 80%). 2. Therapeutic efficacy can be excellent in some patients. 3. Neurodynamic sequencing as a mechanical method of assessment of the neural structures has been well supported with cadaver and in vivo studies ... and the list goes on. The problem is that the literature on this has not been read widely and I feel that it is my responsibility to bring it to the fore as a way of helping my patients. The references for this are provided in my book (see [URL=http://www.neurodynamicsolutions.com)]www.neurodynamicsolutions.com)[/URL]
Thanks for bearing with me: Michael Shacklock
_____________________________
Michael Shacklock
MAppSc, DipPhysio
Director
Neurodynamic Solutions (NDS)
6th floor,, 118 King William Street
Adelaide 5000, AUSTRALIA
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Re: Look at this validation study guys, worth reading! - January 15, 2005 11:44:00 PM
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nari
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From: Australia
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Michael
Thanks for your thoughtful post.
I look forward to your book and I hope others will consider perusing it as well.
Nari
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Re: Look at this validation study guys, worth reading! - January 16, 2005 1:37:00 AM
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childsjd
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Michael:
The offering of new ideas is always welcome, but my suspicision (which has been repeatedly proven in this forum over the last few days) is that one's self-promotion of their courses, book, etc. gets way out in front of the evidence to actually support what they are saying.
You make the following statement: "It is unfair of any representative of any particular group to say that another group's point of view is of little value because everyone actually helps in some way" This is utter nonsense and overly sensitive. Many in our profession do much more harm than good making baseless claims and masquerading their latest idea as science.
You also say the following: "I supervise research at the local university and I am also on the international adivsory board of one of the more notable peer-reviewed journals." Please post in this forum exactly which journal this is. I am curious because if you supervise local research, why is it that you don't have a single publication of original research (other than a case study 5 years ago) to your name in journals indexed in Pubmed!!! There is nothing wrong with being a full time clinician who has no interest in participating in original research. I am not at all critical of these folks. However, I am astounded by the number of folks who pretend to be researchers as a front to promote themselves. I will not be one of the individuals buying your book because I have an incredibly difficult time imagining how you presume to be helping patients when I doubt you can show me one single outcome study that your approach is at all actually effective.
John
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Re: Look at this validation study guys, worth reading! - January 16, 2005 3:18:00 AM
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Jon Newman
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Hi John,
While I think your study was nicely performed, I think your demand that everyone start manipulating to the exclusion of what they are currently getting results with is over emphasizing your findings. This was a validation study. It validated whom manipulation worked on. It would be factually incorrect to state that it works better than what others are doing. Although you have every right to stick your tongue out at those who haven't performed a regression analysis on all their patients who get better so that they can predict who they are getting better. Clearly PT's not manipulating are getting people better, right? Our profession has been doing this for a long time. By the way, what is the "harm" that others are doing (note that I don't disagree)?
While this was a great study, I am disappointed that the comparison group wasn't another form of manual therapy that included multiplanar ROM of the spine. Why wouldn't you have done that? Spinal stabilization has evidence to prove that it works already so why include it? I think there was more for our profession to gain from the alternate comparison personally.
One more question; on your beliefs questionnaire, how many were at least somewhat confident that spinal stabilization would make them better?
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 16, 2005 5:56:00 AM
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childsjd
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Jon:
First, I have said this repeatedly here. I am not suggesting that all patients with back pain need to be manipulation. It's about matching the right treatment to the right patient. In this case, there's a subgroup of patients who dramtically improve (50% reduction in disability in less than 1 week) with manipulation. The stabilization intervention is the perfect comparison group for exactly the reason you outline -- there is evidence for it! In other words, manipulation has to be even that much better to overcome a comparison treatment that is effective for at least another subgroup of patients. To answer your other question, 78/131 (60%) patients in our study indicated an expectation that manipulation would be at least somewhat likely to benefit them.
I would ask the following, How in the world do you presume to know that you patient is getting better unless you measure it? Can anyone here tell me what their avergage change score is on the Oswestry for their patients with back pain? The point is that while you may think your patients are getting better, you really have no idea unless you have some systematic way of recording outcome. We know from multiple studies that patients with back pain may initially improve, causing us to feel good about ourselves and discharge them as if something we did contributed to that improvement. The problem is that many of these folks go on to develop recurrence or don't ever really improve (despite what you may think) and seek care elsewhere. So did we get that patient better or not? Bottom line, you have no idea whether what you are doing is at all helpful until you can demonstrate it with data.
There were about 7 patients in our study who were positive on the rule and were randomized to the exercise group (ie, didn't receive manipulation). All but 1 of them sought care from a chiropractor after being discharged from PT. The point is that if we don't provide care that is effective for the right subgroup of patients, they will seek it from someone who will.
John
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Re: Look at this validation study guys, worth reading! - January 16, 2005 9:59:00 AM
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Jon Newman
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Hi John,
The way I know my outcomes is that I've used the Oswestry for years and the RMQ just over the last year. I tried keeping an outcomes tally but I just didn't have the organizational motivation. Productivity, life outside of the office (which isn't much if you consider how much time I spend on these sites), etc. 50% reduction in the score has been my goal with some patients, and I achieve it. Those would likely be the ones with the low FABQ and short duration of pain. Sometimes I just put a goal of >6 points to indicate a clinically significant amount of change. I meet these goals regularly but I can't tell you average change, sorry.
If a patient attributes their pain relief to the manipulation, why would they feel obligated to go on to exercise? If they get a recurrence, what are they likely to feel the solution is? I think figuring out if it is the manipulation or some other mechanism (like multiplanar ROM in addition to many other variables) is crucial to avoid the misperception of the patient in what is making them better and what they need to do for enduring relief.
Like you, I think combining ideas from one research study with ideas from another is a legitimate clinical practice and is ubiquitous in health care.
Those 6/7 who went on to seek manipulation sound as though they were seeking care concordant with their beliefs. I think that this is tragic if their beliefs are wrong. If their beliefs aren't wrong, then I think it's tragic that we aren't trying to prove that to ourselves instead of just showing 'it works'.
I'm still curious about the rest of my many many annoying questions but mostly that one about those that were positive on beliefs and negative on the rule versus those that were negative on beliefs and negative on the rule.
Thanks for your patience; you can send a sympathy card to my wife if you wish.
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 17, 2005 2:36:00 AM
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bravocosta
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Hello John,
Excellent study. Having reread many of these posts from PT's that are passionate about what they do , the general theme tends to be comments made based on "opinion", "belief", "philosophy of care", or experience. None of these passes the muster as evidence, although they are a part of everyday clinical reasoning. My own experience had been a bias against maninpulation of the L-spine, but in light of recent evidences to the contrary I was likely mistaken in my thinking, as there are several studies demonstrating the efficacy of this approach in acute LBP. Forum posters have every right to their opinion, but it is just that an opinion. The exclusion criteria are an important step of course to identify those likely to benefit. As to "do no harm", where are the evidences that this approach has been harmful?
Patient "dependency" is not an issue as there is not repeated manipulation being performed. If there are significant reductions in subjective pain, this should enable a quicker resumption of activity. How many PT's still advocate specific exercises in the first 2 weeks of acute LBP ? I did this based on my philosophy and belief systems, but the evidence was contrary to my "experience". Sorry for the rant....
With regards to all ..Thomas
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Re: Look at this validation study guys, worth reading! - January 17, 2005 2:42:00 AM
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michaelshacklock
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John, thanks for your response.
I take and agree with your point about presenters saying things that don't relate to good evidence. I acknowledge also that many presenters' primary motive is to benefit financially from their presentations rather than solve the clinical problem. I relate what I can to the evidence but not all is proven, even these days. There is actually a lot more evidence for the neural stuff than anyone imagines and I am in the process of committing to writing an analysis of the evidence, for and against, as a means of addressing this issue. Your point that my writing is not published in peer-reviewed literature is incorrect. But an unfortunate problem that supports your contention here is that some of the early literature on neurodynamic testing (formerly neural tension testing) was published at conferences in Australia. At that time, these proceedings were peer-reviewed and are rated amongst the best in the world as far as scientific quality is concerned, although they were not as rigorously reviewed as is the case these days because we have progressed a long way since then. I'm talking about the 1980s and 1990s. Another problem is the proceedings from these conferences reached the UK and Europe but were not disseminated as much in the United States. So, with all respect, the American knowledge of neurodynamic testing and treatment has not grown at the rate of these other countries.
Furthermore, I actually have published original research and my dissertation is also published but in those days the physiotherapy literature was not indexed on pubMed and I presume that it has not been placed there retrospectively. Also some of the publications I have written were on invitation by the Australian Journal of Physiotherapy and the New Zealand Journal of Physiotherapy which are peer reviewed. I have also published in conference proceedings in the Musculoskeletal Physiotherapy Australia, in Canada, the journal Physiotherapy and given keynote addresses to physiotherapy conferences around the world and an occasional international sports medicine conference. The research that I supervise is performed by post-graduate students and unfortunately they somehow have a terrible record for submitting publications. I suspect that this is because they just want to get out of there as soon as possible after they have finished their post-graduate degree. I can't force them to publish because they are the first and originating researcher. Please bear in mind that all my work at the university is on a no-fee basis and I have to be a full time clinician just to make ends meet. No positions are available for paid research because funding has been reduced by over 50% in the last 5 years. Whilst doing this work, plus looking after my children, I've written 120,00 words in my book and created a system that I hope helps to classify nerve root disorders and attempts to link ALL of the treatment techniques to causative mechanisms. Evidence for therapeutic and diagnostic efficacy for this is in my book (eg. Rozmaryn et al 1998, Sweeney and Harms 1996, Coveney et al 1997, Selvaratnam et al 1997 Tsai 1995, Zorn et al 1996 and so on). There is also excellent evidence that inter- and intra-examiner reliability for performing diagnostic neurodynamic tests is excellent for location of symptoms and range of motion. And, the evidence does exist, you just have to read it. I challenge anyone to perform and supervise research for no fee, write a book in their spare time and give $20,000 of the royalties of their book to the Physiotherapy Research Foundation.
I see with interest your article related to the validation of your clinical technique for determining who will and will not respond to manipulation. I think it is a good study and contributes well to our need for more good quality information on the subject. But it is very easy to be critical and sweat the small stuff as a way of being negative to others. Everyone's research is open to criticism because no study is perfect. Yours study and your subsequent comment in the Annals of Internal Medicine is a good example, criticism of which I notice has been omitted from this chat site.
The criticism goes as follows:
20 April 2004 Annals of Internal Medicine Volume 140 • Number 8 667
Drs. Childs and Flynn erroneously concluded that our review states that spinal manipulative therapy does not work. The data we reported show that spinal manipulative therapy is more effective than either a sham manipulation or ineffective therapies. The data do not show that spinal manipulative therapy is more or less efficacious than other advocated therapies. Dr. Shapiro erroneously concluded that spinal manipulative therapy as defined in our report was “thrusting or high-velocity, low-amplitude technique” and that “in reality, manipulation is an eclectic group of techniques.” In contrast, we specifically acknowledged the heterogeneity of techniques that are considered manipulative therapy and included in our review studies that specifically excluded high-velocity techniques. We performed sensitivity analyses on our pooled results by separating them into the studies that specifically used high-velocity techniques versus all others; we did not find any difference in our results. Last, Drs. Childs and Flynn and Dr. Shapiro adhere to the common belief that there is an identifiable subgroup of patients with back pain who will have a very good response to spinal manipulative therapy but no other therapy. The clinical prediction rule cited by Drs. Childs and Flynn was developed from a cohort of 71 patients, all of whom received spinal manipulation; therefore, it is impossible from these data to conclude anything about the response of these patients to spinal manipulative therapy versus any other therapy or even no therapy. Of note, the most strongly predictive variable in this clinical prediction rule was duration of pain, which most strongly predicts recovery even in the absence of treatment. We know of no data that will allow the clinician to identify in advance those patients with back pain who will respond better to spinal manipulative therapy than to other active therapies, or even that such a population patients exists. If it does, the data we reported suggest that it must be small.
Paul G. Shekelle, MD, PhD
Sally C. Morton, PhD
RAND
Santa Monica, CA 90407
Willem J.J. Assendelft, MD, PhD
Dutch College of General Practitioners
Utrecht, the Netherlands
In spite of this criticism I still think your work contributes to the overall good and you should continue your work in this area. But please bear in mind that a supportive and challenging problem solving approach actually helps develop knowledge much better than sweating the small stuff, unless the small stuff is the main problem.
Once again, thanks for bearing with me. I'm over and out on this discussion.
Regards,
Michael Shacklock
_____________________________
Michael Shacklock
MAppSc, DipPhysio
Director
Neurodynamic Solutions (NDS)
6th floor,, 118 King William Street
Adelaide 5000, AUSTRALIA
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Re: Look at this validation study guys, worth reading! - January 17, 2005 4:50:00 AM
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Diane
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So glad for this new post. Solves the mystery of "where is the research"... The Aussies were so far ahead of the times that pubmed has missed them almost completely. Too bad.
[QUOTE]There is actually a lot more evidence for the neural stuff than anyone imagines and I am in the process of committing to writing an analysis of the evidence, for and against, as a means of addressing this issue.[/QUOTE]Michael Shacklock, I can't wait to read your book, if this is what it will contain...
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Re: Look at this validation study guys, worth reading! - January 17, 2005 5:56:00 AM
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Bournephysio
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I think that it is important to point out that the above criticism is dated before the study we are discussing. It looks to be about comments made by Childs and Flynn as well as the regression study that developed the rule. The criticism about the previous study is a good one: manipulation was not compared to another group. That was not the nature of the study. This criticism has been answered with this randomized control trial.
Doug
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Re: Look at this validation study guys, worth reading! - January 17, 2005 12:06:00 PM
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michaelshacklock
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Hi Diane, many thanks for your comments on the neural stuff. Yes, it is very unfortunate that the research did not reach some important forums for discussion and peer-review. Hence, my commitment is to foster dissemination of the material so that the subject is better understood. My new book, Clinical Neurodynamics, links the causative mechanisms with treatment techniques in a way that integrates musculoskeletal function and physiology of the nervous system to diagnosis and treatment in a systematic way. Much of the evidence for this is presented but the specific evidence in terms of inter- and intra-examiner reliability is not. I deliberately left this out because I thought that it would make the book too long-winded and unappealing for the CLINICIAN who needs practical solutions. However, I accept the challenge to provide better evidence in the future so that this approach becomes more acceptable to our patients and practitioners.
Best,
_____________________________
Michael Shacklock
MAppSc, DipPhysio
Director
Neurodynamic Solutions (NDS)
6th floor,, 118 King William Street
Adelaide 5000, AUSTRALIA
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Re: Look at this validation study guys, worth reading! - January 17, 2005 1:04:00 PM
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childsjd
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Michael:
I can see that you're missing the message I am trying to communicate and don't find it useful to rephrase again here. I still haven't seen you show me the outcome data suggesting your approach is effective (nor has anyone else to whom I've posed this question). We actually have some outcome data in a small trial to be published soon that will lend some credibility to these ideas, so I suppose you can thank us later that someone is actually doing something about the evidence abyss that exists in this area. It amazes me the lack of understanding among some in this forum as to what constitutes evidence.
Also, as Doug points out, your quote from Assesdelft above was a response to a letter to the editor we published with respect to their systematic review. The limitations they are referring is directed at the original development study for the prediction rule (which was the initial step in the development of the rule, thus these criticisms were expected and understood well before the study was carried out). I'm sorry for undermining your attempt at "gotcha" above, but the RCT we just published answered these issues directly, thus these concerns no longer apply. It would be helpful if those interested in criticizing someone's work (which is expected and helpful to generate new ideas so criticism is always welcome) would actually take the time to read the studies and notice the date discrepancies rather than sounding off in an unintelligent manner. Hope this clears the air.
John
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Re: Look at this validation study guys, worth reading! - January 17, 2005 3:10:00 PM
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nari
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John,
This thread has had its run, for sure.
It is unfortunate that some have missed the message. Only there are two messages - and each is playing quite a different tune. Which is good for the profession and stops us being painted into a corner by rhetoric and rules and regulations.
In the meantime, perhaps we will get on with doing what physiotherapists do best - restore functional mobility by whatever method in the repertoire seems appropriate for the patient.
Nari
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Re: Look at this validation study guys, worth reading! - January 17, 2005 3:17:00 PM
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michaelshacklock
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John, thanks for your reply. I'd appreciate the paper you mention when it comes out. All the best, Michael
_____________________________
Michael Shacklock
MAppSc, DipPhysio
Director
Neurodynamic Solutions (NDS)
6th floor,, 118 King William Street
Adelaide 5000, AUSTRALIA
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Re: Look at this validation study guys, worth reading! - January 17, 2005 8:32:00 PM
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steve
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This thread boggles my mind - if you feel your approach is as good or better than John's go out and prove it! To sit back, state your guru status and then expect everyone to accept it on this basis is archaic.
Someone stated that the clinical prediction rule makes you a technician - nothing could be further from the truth. We are clinicians and scientists who take evidence in order to provide the best possible care for our patients. To do any less would demean our profession.
If you are not looking at the evidence critically and applying it to your practice, how is anyone going to differentiate you from the snake oil sellers?
Steve
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Re: Look at this validation study guys, worth reading! - January 17, 2005 11:49:00 PM
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michaelshacklock
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Steve, I agree with you. And please don't think that I think my approach is better than anyone else's because I would never say that. It is just that in some people who are carefully selected, I think that some patients will do better than others and vice versa. In those that do not have a neural problem, neural techniques will be of no value. And you are right about application of the evidence. We should definitely apply the evidence to the clinical situation, as best we can. However, in clinical decision making, we have to be cautious about treating patients according to studies such as RCTs because each patient houses subtle nuances that will give us clues about what they need and many methods of study simply do not at this stage pick them up. Maybe one day they will.
Also, please don't think that I was blowing my own trumpet before about what I have done. I personally don't rate my performance very highly because there is much more to be done. My frustration has been trying to do research without any funding and combine the need to earn an income. The reason I presented a bit of a bio' before was to answer the question about what research I have done and why much of it has not reached PubMed, also to illustrate my commitment to establishing good evidence in sometimes adverse circumstances. And you are right, reputation or credentials bear no relationship to fact. The proof is in the research outcomes.
Finally, I should be more specific about the evidence I mentioned earlier. The outcome studies that have been performed in relation to neurodynamic testing and treatment are as follows so that readers here can get some idea of where the studies are published. This goes back to my point that many of these studies were published Down Under and did not reach the eyes of some northern hemisphere countries.
In relation to therapeutic efficacy, Rozmaryn et al (1998 Journal of Hand Therapy). Showed that nerve and tendon gliding techniques were associated with reduced need for surgery in carpal tunnel syndrome sufferers by 35-40%.
Sweeney and Harms (1996 Journal of Hand Therapy also) showed that neural mobilisation techniques gave a better result in patients with peripheral neuropathies that other therapies. Admittedly, the other therapies weren't that great.
In relation to diagnostic efficacy in carpal tunnel syndrome, our group showed that the upper limb tension test 1 has been shown to produce a sensitivity rating of 82%, specificity rating of 75% and positive predictive power of 93%. This has been shown in two studies that were conducted independently of each other (Coveney et al 1997 and Selvaratnam et al 1997 both in the proceedings of the Manipulative Physiotherapsists' Association of Australia, Melbourne pp 31-33 and 182-188 respectively).
At this point one can say three things: The results are good. We don't know whether these results are applicable to other parts of the body. There is much more work to be done before the jury will rest.
I could write a lot more about this but in the interests of other contributors and readers, I'll close off for now. But if anyone else is interested in more on this subject, I'm only too happy to reply as informatively as I can.
Thanks for reading this.
Michael
_____________________________
Michael Shacklock
MAppSc, DipPhysio
Director
Neurodynamic Solutions (NDS)
6th floor,, 118 King William Street
Adelaide 5000, AUSTRALIA
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Re: Look at this validation study guys, worth reading! - January 18, 2005 3:35:00 AM
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ericm
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The voracity of the personal attacks in this thread are remarkable. I wonder where this aggression comes from? Fear? Lets not shoot the messenger guys. It is as much my fault, as it is yours, or anyone elses for not having put new theories through systematic trials. To be ignorant of the theories is no excuse and to blame the theoretician is nonsense.
eric
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Re: Look at this validation study guys, worth reading! - January 18, 2005 5:18:00 AM
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PTupdate.com
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Steve,
Your thread basically contradicts itself. People in this thread ARE looking at the evidence critically, and asking questions and challenging things. This is a good thing. Too many clinicians read just the headline for an article and say "Well, it's in a journal, it must be true". Others just read the abstract, and the fewest read the whole article. I personally do not know one PT that reads the entire article and then dissects the methods.
I will not stop things that I use to treat just because there is not a killer evidence study out there. Most of what I do has support in the literature, and I support this study because it does give me an option for certain patients....an option I have already used for years.
Duffy
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: Look at this validation study guys, worth reading! - January 18, 2005 5:25:00 AM
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childsjd
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Eric seems to be bothered by a perception that we are attacking each other. I can't speak for others, but I assure you I am not personally attacking anyone, just someone's ideas. I iamgine many of the individuals whose ideas I am criticizing would be the very type of individual with whom I might have a personal affinity -- ie, someone who is not afraid to speak their mind, however uninformed it may be in my opinion. This is merely my jusdgment, but one of biggest problems in our profession is that we are so sensitive that we have lost (or perhaps never had) any ability to critically think and examine the credibility of what someone says. Our tendency is to take things at face value and be persuaded by lots of flowery language and anecdotal stories about what works "in my hands...".
My criticim of textbook authors is that they almost universally use authoritative language that may be light years ahead of what the peer-reviewed evidence actually suggests, or even directly conflicting. References are largely based on theoretical evidence which may have absolutely nothing to do with the realities of real patients with real pain and dsiability. Uninformed consumers of this propaganda often translate this information as "then I should be doing this in my practice". Because textbooks are not peer reviewed, authors are given excessive editorial latitude to make outrageous claims (some of them well intended and simply not informed about the genuine meaning of evidence-based practice). Increasingly, the peer-reviewed literature can guide our decision-making, yet an entire generation of physical therapists continue to seek their "evidence" from textbooks. I echo Sackett's call that we burn almost all of our textbooks, other than perhaps the basic science and other technical textbooks (stats, EBP, etc.). Almost all others (with a few exceptions here and there) are filled with gross exaggerations about what the evidence really has to say about a particular topic. Even if the recommendations are consistent with some semblance of the evidence, they are so outdated by the time we read them that they are practically useless in most cases. Clinical reasoning will always be an integral part of evidence-based practive. However, one cannot begin to presume being an evidence-based pratitioner unless he or she is current in the peer-reviewed literature. Enough of the soapbox, but Steve you captured my long diatribe in a nice, succinct manner.
John
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