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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 18, 2005 7:13:00 AM
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Alex Brenner PT MPT OCS
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[QUOTE].....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.
[/QUOTE]I agree with the above statement. Another area we have to be careful with is the Cochran reviews. Someone on another thread mentioned that they liked these because the work was done for them. You have to be real careful here, for example, the Cochran review findings that manipulation was not effective for lower back pain. The error that was made in regards to their review was lumping all low back pain into one group. Doing this will lead to erroneous conclusions. We know from recent studies that separating low back pain into categories or groups has merit. I think we are finally on to something here, certainly more research needs to be done in this area. These are indeed exciting times in our profession!
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Alex Brenner, PT, MPT, OCS
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Re: Look at this validation study guys, worth reading! - January 18, 2005 7:53:00 AM
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Jon Newman
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Hi John,
If you're not sick of my questions yet I've got another. What percentage of the subjects who were positive on the rule were injured at work?
Also, I've started a thread in the open forum as it pertains to EBM. You're invited (everyone is of course)to participate there. I'm afraid that, similar to last time I posted this article, no one will participate.
Thanks,
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 18, 2005 8:36:00 AM
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childsjd
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Jon:
I don't have an exact figure in front of me, but it was a small percentage. We work not specifically looking for work-related LBP.
John
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Re: Look at this validation study guys, worth reading! - January 18, 2005 10:13:00 AM
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Jon Newman
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Hi John,
First, thanks for continuing to answer my questions. I'm hoping this is my last one. I tried to figure out which factors explained their portion of the variance the most. I only found the information for duration of symptoms. Could you rank order each predicitive variable according to its contribution and how much of the variance is explained by that variable? Thanks,
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 18, 2005 10:30:00 AM
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childsjd
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Jon:
Good thought, but you can't really rank in order of importance based on explained variability because they each contribute different pieces of information, with some being more sensitive, others being more specific. However, acuity of symptoms and location of symptoms had the largest univariate positive likelihood ratios. There is a secondary analysis currently in review looking at the accuracy of just these two factors, which makes the rule quite pragmatic for a busy primary care setting where referring practioners can quickly assess a patient's status on a modified, but still highly accurate, rule. Hope this helps.
John
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Re: Look at this validation study guys, worth reading! - January 18, 2005 11:24:00 AM
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Andrew M. Ball PT PhD
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From: Charlotte, NC
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John,
Have you found any patients that initially scored 3/5 on the rule, and then (say with a few treatments improve their internal rotation range to greater than 35), achieve 4/5?
I ask as I have one such patient right now who may fall into that category (the other negative being a Waddell of more than 40). While some PT's and chiropractors would simply go ahead and manipulate, I'm hesitant to do so without the ClinPredRule to back me up --- especially being:
1. In a state (North Carolina), where I have to ask "physician may I?" before using a manipulation/grade V mobilization and tend as a result to choose my patients very carefully and conservatively.
2. Working with several physicians (this patient's being one of them) that either "don't believe" in grade V's, or require a load of case-by-case justification before going ahead with the technique (although your JOSPT article, and I hope once I get my hands on your new article, will assist me in quicky communicating just that).
Have you come by this situation of 3/5, likely to soon be 4/5 before? If so, how did you handle it clinically? Did you refrain from grade V, or did you give it a try thinking that the patient might be in that 45% (is this stat right?) or so that will have a positive clinical outcome despite negative on the ClinPredRule?
Drew
P.S. Keep in mind that while I'm reading a ton of ortho articles, my area of clinical, research and publication expertise is really pediatrics (Infants and Young Children), and Health Education Management (Journal of PT Education, Cost and Quality, etc.). I've only been in the ortho clinic for about a year --- hence high level understanding of research, statistics, publication process and neurodevelopmental pediatrics --- but gaping holes in other areas of clinical care and clinical research.
THANKS FOR BEARING WITH ME!
_____________________________
Dr. Andrew M. Ball, PT, DPT, Ph.D.
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Re: Look at this validation study guys, worth reading! - January 18, 2005 11:57:00 AM
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childsjd
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Drew:
Glad to bear with you. Helping clinicians make decisions about patients is what translating evidence into practice is all about. First, in terms of your referral sources, I would encourage you to educate them about the prediction rule by providing them copies of the articles (JOSPT, Spine, and Annals of Internal Medicine). You can get access to the full text paper in Ann Int Med off the APTA website if you are a member through the Foundation's press release about the paper. By the way, please don't tell me if you're not a member, as I don't want to change my perception that you're a contemporary therapist interested in moving the profession forward. Seriously though (although only half kidding), if you email me privately, I would be happy to provide you copies of the articles.
In terms of 3/5 versus 4/5, don't think about the rule as being a binary decision (ie, manip if 4/5, don't manip if less than 4/5). Remember, the reference criterion for a successful outcome was 50% improvement in disability in 1 week, which corresponds to dramtic improvement. Therefore, many patients who may not meet at least 4/5 will still benefit from manipulation, just not experience the dramatic improvement. Also, the post-test probability of successful outcome in patients with at least 3/5 factors present was around 70% (compared to 92% for 4/5), thus an attempt at manipulation seems prudent with at least 3/5 present since the technique is easy to perform and poses essentially negligible risks. With 2 factors present, the likeihood of getting a dramatic improvement begins to approximate that of chance (roughly 45%). With 0-1 factor present, you're probably not going to observe a dramatic improvement (less than 10% chance) with the technique we used, thus looking elsewhere is probably in order. Again, you're not going to harm patients you manipulate with less than 3 criteria present. They just may not experience much improvement.
The take home message is this. It makes logical sense to manipulate patients with at least 3/5 present. The real take home message though is that you have to really question why someone would NOT manipulate a patient with 4 or 5 criteria present because the odds get close to 100% that the patient will experience a 50% improvement in disability if you do. There is simply no other treatment we know that can generate this magnitude of improvement in such a short period of time. Therefore, the rule is extremely helpful for helping clinicians determine who they want to be sure gets offered spinal manipulation (ie, at least 4/5). Hopefully this makes sense. Let me know if you have any questions.
John
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Re: Look at this validation study guys, worth reading! - January 18, 2005 12:30:00 PM
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Jon Newman
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Hi John,
Maybe I'm confused. I thought this statistical model produced a mathematical equation that produced a regression coefficient for each variable. My question was directed at what those coefficients were.
Drew, you should also take into account your patient's oswestry score. It should be greater than 30% which is not part of the prediction rule but is part of the inclusion criteria.
jon
An afterthought: In this validation study, why was the extensive clinical testing performed again? Why not just use the rules and manipulate, that's all. That would have made it more similar to what you're imploring others to do.
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Re: Look at this validation study guys, worth reading! - January 18, 2005 1:06:00 PM
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Andrew M. Ball PT PhD
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John,
Works for me. Thanks for the answer. As an aside, I've been a member of the association as long as I've been a PT, one kind of has to when they complete their PhD dissertation on the subject of membership/joining behaviors of health professionals in their professional organizations.
The only exception for that has been this year. My wife, also a PT, and I don't see much reason for both of us to spend $350 per year plus sections, plus the AAOMT membership, etc. My discussion last year at APTA headquarters regarding my findings, and the recommendations to consider both section-first membership psychology, as well as reduced rates for PT's married to PT's have yielded much discussion, but not much actionable change due to transition costs. It's not so much the cost, so much as not needing two copies of the journal --- and wanting either a reduction in dues in return --- and/or a re-allocation of those funds for better professional use than killing an additional tree.
Anyway, we both end up getting great access to the association as we join more sections than we otherwise would.
What I don't have, however, is her membership number and password (I've not accessed much along the lines of web-based member's only stuff for a while) --- I'll ask her when she gets home and e-mail you if I have any problems. Thanks for the offer of e-mailing your article, but I shouldn't need it.
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 18, 2005 1:12:00 PM
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Diane
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From: Vancouver, B.C., Canada
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John,
Do you count muscle energy technique as spinal "manipulation", or just HVLA grade Vs?
I asked this question earlier, page 3 of this long thread, I think.. but it was overlooked/ignored... (I'm not an APTA member because I'm Canadian, so can't get easy access to your article to find out for myself.) Perhaps, since you seem in a question answering mood, you would be willing to give a quick yes or no answer to this.
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Re: Look at this validation study guys, worth reading! - January 18, 2005 1:26:00 PM
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childsjd
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Diane:
It really depends on the terminology you want to use. Perhaps thrust and nonthrust manipulation is a good way to differentiate. The APTA has chosen the mobilization/manipulation language. For the low back, high velocity thrust procedures are superior, thus it's hard to be on the side of the evidence and argue that you're not going to manipulate (ie, thrust technique) patients with back pain. The neck is a different story (and for another discussion). Bottom line is that the prediction rule can only be generalized to the technique we used, not lower velocity mobilization procedures, muscle energy, or even other thrust techniques. That's the advantage of the rule -- one simple technique helps lots of patients. Ultimately future research will determine whether the choice of technique matters. Perhaps there's just something about getting the region moving again that's the key (aghast -- regardless of the level of force or direction). Many of our sacred cows will likely continue to be "de-throned" as new evidence emerges. The question really then becomes -- Will we let go of those sacred cows? Time will tell, but there are several posting in this forum who are clinging to many sacred coww that have long since been buried. Getting better, but we have a long ways to go.
John
John
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Re: Look at this validation study guys, worth reading! - January 18, 2005 1:31:00 PM
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childsjd
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Drew:
Thanks for your candor. It's refreshing to see folks willing to come right out and make their case, at the risk of being criticized. Feel free to send me an email at childsjd@sbcglobal.net with a request for the articles. I would be glad to send.
John
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Re: Look at this validation study guys, worth reading! - January 18, 2005 1:32:00 PM
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childsjd
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Diane:
I would also be glad to email you a copy of the article since you don't have access. Just send me a request to childsjd@sbcglobal.net.
John
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Re: Look at this validation study guys, worth reading! - January 18, 2005 2:28:00 PM
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Jon Newman
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Hi John,
You stated: "For the low back, high velocity thrust procedures are superior, thus it's hard to be on the side of the evidence and argue that you're not going to manipulate (ie, thrust technique) patients with back pain."
Superior to what?
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 18, 2005 3:51:00 PM
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Bournephysio
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If anyone is intersted I found a link to John's PhD thesis. It includes an mpg of the manipulation and copies of the FABQ and oswestry and other forms used in the study.
[URL=http://etd.library.pitt.edu/ETD/available/etd-08222003-013408/]Validation of A Clinical Prediction Rule to Identify Patients Likely to Benefit from Spinal Manipulation: A Randomized Clinical Trial[/URL]
Doug
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Re: Look at this validation study guys, worth reading! - January 19, 2005 2:13:00 AM
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childsjd
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Jon:
The regression coefficients you may be referring to are related to the initial development study, but I don't think they are reported. We don't report regression coefficients in the Annals paper, other than for the adjusted odds ratios (which is not what you're asking about). Again, the more valuable statistic for the purposes of decision-making is likelihood ratios. Does this help?
In terms of my comment about manipulation being superior, I am referring to mobilization (ie, nonthrust manipulation). The effect sizes for manipulation are generally larger than those for mobilization. The same is not true for the neck, where mobilization techniques seem to work equally as well as thrust techniques (again, generally speaking).
John
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Re: Look at this validation study guys, worth reading! - January 19, 2005 2:16:00 AM
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childsjd
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Doug's post reminds me. There is a Flash file that serves as Appendix 3 in the paper. You can see a full video demonstration of the rule and the technique by going to the following website: http://www.apta.org/Foundation/news/spinal_manipulation. You can also get to it at [URL=http://www.evidenceimotion.com.]www.evidenceimotion.com.[/URL] Let me know if you have any questions.
I should have sent this a long time ago, as it may have cleared up some of these issues earlier.
John
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Re: Look at this validation study guys, worth reading! - January 19, 2005 2:37:00 AM
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Shill
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John,
Has anyone asked specifically what the ROM exercise performed by the manipulation group was?
Just curious. Was this selected to make the treatment more clinically relevant, since it isnt likely that one would just get manipulated in the clinical environment?
Thanks,
Steve
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Steve Hill PT
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Re: Look at this validation study guys, worth reading! - January 19, 2005 3:24:00 AM
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Diane
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Tip: John's links will work if you delete the period at the end of the url.
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Re: Look at this validation study guys, worth reading! - January 19, 2005 3:31:00 AM
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Diane
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From: Vancouver, B.C., Canada
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Tip: John's first link will work only if you delete the period at the end of the url (i.e.: http://www.apta.org/Foundation/news/spinal_manipulation .) The second link is misspelled.. should be [URL=http://www.evidenceinmotion.com]www.evidenceinmotion.com[/URL] , not evidenceimotion.
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