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RE: Whacking, Cracking, and Chiropracting
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RE: Whacking, Cracking, and Chiropracting - November 4, 2007 10:27:03 PM
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goodlooks58
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Yes, I agree but the PTs have a huge negative: The advent of corporate PT i.e. Novacre and the likes of it. Here the bottom line is showing a profit of a minimum 20% every year. Also, here the quality is definitely going to be compromised in lieu of quantity.
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RE: Whacking, Cracking, and Chiropracting - November 4, 2007 11:30:58 PM
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Jon Newman
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From: Amherst, WI
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Hi Proud,
quote:
The evidence speaks and it's time to move from theory based to evidence based--proud
Those concepts are not mutually exclusive categories as you make it sound nor is an effective clinician likely to run their practice in the absence of either.
How do you see the "one expert" scenario unfolding? Is it going to be a legislative effort? A market demand? A combination of the two or something else that I'm not currently envisioning?
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RE: Whacking, Cracking, and Chiropracting - November 5, 2007 2:44:33 PM
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TLB
Posts: 346
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From: Arizona
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quote:
ORIGINAL: goodlooks58
Yes, I agree but the PTs have a huge negative: The advent of corporate PT i.e. Novacre and the likes of it. Here the bottom line is showing a profit of a minimum 20% every year. Also, here the quality is definitely going to be compromised in lieu of quantity.
You certainly don't give our fellow PT's much credit. You make it sound as though we as a profession are other people's cash cow whether it be physicians, hospitals, or corporations. You know what? Your right.
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RE: Whacking, Cracking, and Chiropracting - November 6, 2007 11:03:16 PM
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proud
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quote:
ORIGINAL: Jon Newman
Hi Proud,
quote:
The evidence speaks and it's time to move from theory based to evidence based--proud
Those concepts are not mutually exclusive categories as you make it sound nor is an effective clinician likely to run their practice in the absence of either.
How do you see the "one expert" scenario unfolding? Is it going to be a legislative effort? A market demand? A combination of the two or something else that I'm not currently envisioning?
Jon,
Seems we have two questions here:
1. Correct. Not mutualy exclusive. However Jon, this is a common faulty argument for many theory based practitioners. The "best practice" portion within the commonly quoted Sackett definition of EBM is often mis-used. Jon, when evidence is pretty clear that paraphysiological space is non sequitur in that it does not follow that it is of any clinical relevance based on what is known, we cannot discuss treatment options based on it. Choosing to ignore treatments with known outcomes in favour of more alternative approaches due to anecdotal outcomes is not "best practice" as some would propose. Using theory based approaches( or best practice if you will) is okay when no other approaches based on the outcome evidence is available....AND the theory based approach has not been proven false( specificity of spinal manipulation for example or "maintenance" manipulation for another).
2. Legislative effort. With healthcare costs skyrocketing due to an aging population, insurance premiums through the roof leaving millions uninsured and relying on government support....third party payors will no longer pay for unsubstantiated treatments....no matter how anectodal. And the profession who has demonstrated a commitment to evidence based approaches will become the provider of choice. "After the boom" is a good book describing this aging population crunch and healthcare will be profoundly affected( by 2015 is the prediction). Those that practice on the periphery of theory based approaches will fall to the side. Unfortunately, some patients who may benefit from theory based approaches will have to fund their own treatments...but it is either that or we have millions of uninsured and government dependant individuals. It is going to happen eventually. No real choice Jon.
< Message edited by proud -- November 6, 2007 11:10:47 PM >
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RE: Whacking, Cracking, and Chiropracting - November 7, 2007 12:16:17 AM
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Jon Newman
Posts: 1697
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From: Amherst, WI
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Hi Proud,
I agree with you on the "paraphysiological space" issue. However, the shift from theory to evidence based practice you suggest is a contrivance as a general statement but I'm coming to understand that you probably didn't mean that as a general statement. But in case you did, here's a clarification of what I was getting at. Therapists historically used (and still do use) evidence AND theory to guide their practice and this will continue to be the nature of clinical practice regardless of what can be found in peer reviewed literature. When the evidence is inconsistent with what a particular theory predicts then a number of things should happen, neither of which depend on foregoing either theory or evidence. First, the theory is either wrong in part or in whole (or more correctly, unsupported) and the conflict needs to be addressed through abandoment of the predictions of that specific theory or of the parts found lacking (perhaps a new version would then be named like theory 2.0). The alternative is that the inconsistent evidence is faulty or misleading in some manner.
Regardless, even after the intelligent move of abandoning "subluxation theory" (for instance) I defy you to show me an effective theory-less practice, or conversely a strictly "evidence based practice".
I'm probably being overly nuanced but I get discouraged when I see "theory" being used as a dirty word, unworthy of Physical Therapy.
Thanks for your answer in number two. I don't think it will unfold that way and in some aspects I'm hopeful it won't.
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RE: Whacking, Cracking, and Chiropracting - November 7, 2007 7:45:41 AM
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SJBird55
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Jon, your feelings are somewhat political in nature. You base a lot of your practice foundation on "theory based" because of the therapists you respect. You view "theory" as a dirty word because, at this point in time, the therapists you respect have no clinical evidence to support their theory. Since they have no clinical evidence, yet they believe their theory is strong, you, and each and every one of them, have to mentally defend your rightness in how you choose to practice. In fact, the pendulum has been moving in all of your minds because those therapists that you do respect ARE attempting to provide evidence by attempting to have work published in peer-reviewed journals. This choice of behavior indicates to me that no matter how much they want to kick and scream that "theory based" is relevant and can provide a strong foundation for clinical decision-making, they actually know deep down inside that evidence is what trumps "theory" at the end of the day.
Reality is that yes, clinical decisions are based on 2 spectrums. You've got theory with negative evidence, theory with no evidence, theory with positive evidence. You've got negative evidence with no theory, no evidence with no theory, and positive evidence with no theory. We'd hope that clinicians are practicing at the end of the spectrum of theory with positive evidence or positive evidence with no theory. Reality is that there isn't evidence for everything that we choose clinically, so of course we have to do our best, but we shouldn't find comfort in hanging out and justifying that theory with no evidence is okay.
Politically Proud is probably right. It's shifting that way. CMS is now beginning to consider outcomes and look at outcomes too. If we as a profession can't buck up and show our outcomes, in the end, it is the patient that will lose. CMS has a frame of mind to cut costs.... can you blame them? In cutting costs though, certain procedures are going to be disallowed.
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RE: Whacking, Cracking, and Chiropracting - November 7, 2007 8:55:35 AM
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Jon Newman
Posts: 1697
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From: Amherst, WI
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Hi SJ,
quote:
Jon, your feelings are somewhat political in nature.
I'm assuming you're analyzing my use of the word "discouraged". Yes, it is a feeling with political as well as factual importance. So what?...Oh because,
quote:
You base a lot of your practice foundation on "theory based" because of the therapists you respect.
Do know what my "practice foundation", whatever that means, is? Do you have a list of therapists I respect handy?
quote:
You view "theory" as a dirty word because, at this point in time, the therapists you respect have no clinical evidence to support their theory.
I wasn't the one viewing theory as a dirty word. I was encourgaging others that frame theory as a dirty word to reconsider their opinion.
quote:
Reality is that yes, clinical decisions are based on [evidence and theory]
Yes. My point exactly. The rest of your analysis of motivation, etc is uninteresting and irrelevant. Save it for your diary.
quote:
Politically Proud is probably right. It's shifting that way.
What way? I thought you just agreed that clinical reality requires that both are required for effective practice. Beyond that, doesn't the evidence you rightly advocate for derive from some sort of theory? A quick look at the most recent PT journal helps shed some light on this. For example, from the first article* in the current issue of PT journal (and it's aging related--see reference at end):
quote:
Symptomatic knee osteoarthritis (OA) is a worldwide problem1–4 that produces substantial disability in middle-aged and older adults and leads to a tremendous economic burden on society. The prevalence of OA among older individuals has led some authors to regard its development as a normal part of aging. Loeser and Shakoor, however, suggested that age-related changes in musculoskeletal tissue, such as muscle weakness and ligament laxity, do not directly cause OA, but may predispose individuals to develop the disease. It is possible that the manner in which people respond to these age-related changes in musculoskeletal tissues about the knee may be related to whether or not OA develops in the knees of older adults.
Later
quote:
Another possible precursor to knee OA is excessive frontal-plane laxity...
*
Age-Related Changes in Strength, Joint Laxity, and Walking Patterns: Are They Related to Knee Osteoarthritis?
Katherine S Rudolph, Laura C Schmitt, Michael D Lewek
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RE: Whacking, Cracking, and Chiropracting - November 7, 2007 10:41:47 AM
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SJBird55
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No, Jon, I never said both were required. I offered 2 separate spectrums and suggested the regions within the continuums that included positive evidence which should be a priority in clinical decision-making. That means that it doesn't matter what a therapist thinks, believes or dislikes (i.e. that no theory may be present OR that the theory may be flawed). Since the patient and patient perspectives are always a part of EBM, if the patient decides the approach doesn't fit the patient's perspective, then the patient has final say in the matter (it is the patient's body). The interventions with the best evidence should always be offered first though, regardless of the therapist's personal stance against or disagreement with the evidence. We all like to think that we are special and have a greater understanding than some of our peers, well, we all have our views, but good evidence is good evidence. Incorporating good evidence is not selling our uniqueness out and it isn't a matter of just following a cookbook either. When there is good evidence, the evidence does a pretty good job (generally) in describing the patient population that will respond. Reality is that it is all about the patient and getting the patient back to as normal of a life as possible as quickly as possible - it isn't about the provider, the provider's unique thoughts or how special the provider is.
The bottom line is that third party payors and legislators have a priority of cutting costs. I believe that there will be an attempt made to reward and allow for services that provide the most effective care. Effective care will probably begin to be defined by the third party payors and legislatures. One would hope that evidence would be used in making those decisions and that we, the providers, have evidence with regard to the care we provide. One particular third party contract here in this state has defined "effective care" as an average of 10 or less visits per episode of care (no matter what the patient complaint). Poor risk-adjusting occurs based on claim data such as age, gender and body part with no additional variables that have a definite impact on the actual rehabilitation potential. Physical therapist providers of care are being monitored on number of visits since the defined standard by the third party payor is number of visits. Big problem with that as the definition of quality - the third party payor has no clue how effective the episode of care was. Another example: the finalized fee schedule is also alluding to data collection and analysis to assist with cost reduction payment alternatives. There will be no way to argue "theory" with any payor. Payors have no regard for theory. Payors care about results. Results in a timely manner and results that do not have the subscriber re-entering the medical system for the same problem. Politically the pressure is going to be on providers. Providers are going to have to prove their value and their worth - if it can't be proven through results, what is "allowable" is going to change. As Proud mentions above... there is going to be a weeding out of those that "think" they get results from those that DO get results.
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RE: Whacking, Cracking, and Chiropracting - November 7, 2007 11:39:20 AM
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Jon Newman
Posts: 1697
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From: Amherst, WI
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Hi Sj,
Sorry for any misunderstanding of your position. As it is our history to talk past each other, I'll make an attempt to understand your position.
1) You think it is not only possible to run an effective practice that is free of theory but
2) it is also a desirable state of affairs.
Is that right?
My thoughts, so it is completely clear, are that it is impossible to run an effective practice without theory and that is undesirable to try.
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RE: Whacking, Cracking, and Chiropracting - November 7, 2007 12:28:31 PM
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proud
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Jon jon Jon,
No one has stated theory is not important. Let's be clear here. Many patients do not fall neatly into reserach accepted forms of treatment. Many many in fact. And so....best practice takes over. Right?
But best practice does not mean two things:
1. Proceeding with a theory based model that has been proven faulty( specific joint "adjustment" to realign the spine for example).
2. Using a theory based approach( no matter how grounded in accepted science), when said approach has had ample time to be investigated and put through the rigors of clinical trials( the chan gunn approach using acupuncture and IMS for example). At some point a lack of outcome data becomes telling indeed.
What is being stated here is that without question, we are facing a pending healthcare crunch. As government becomes leaned on due to millions of uninsured citizens, they will be forced to scrutinize current treatment approaches. I think this is a really really good thing. No longer will we have the "shake and bake" clinics that still exist today throwing heat and IFC on patients, no longer will we have subluxation based chiropractic, no longer will we have clinicians making up their own special blend of treatment when accepted, research based approaches SHOULD be used instead.
Those clinicians that demonstrate a commitment to this will be the provider of choice and thus be given some "space" to implement best practice or theory based approaches when they have clients that fail the current "research" based approaches.
We just cannot have the model we have now continue. It's simply unacceptable. One "expert" provider Jon is the way forward and most third party payors recognize this already. Frankly, I do not want to be associated with the "theory based without data" crew if at all possible when the HEAVY substantiation era begins( somewhere between 2015-2020).
Some patients will lose out to potentially effective unproven techniques, most however will actually benefit. And for the greater majority, it will be clinically more effective and cost effective. Better outcomes at a lower cost....is this not a good thing Jon?
< Message edited by proud -- November 7, 2007 12:37:13 PM >
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RE: Whacking, Cracking, and Chiropracting - November 7, 2007 1:33:45 PM
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Jon Newman
Posts: 1697
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From: Amherst, WI
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Hi Proud,
quote:
No one has stated theory is not important.
Well it sounded like it, hence my original post to you. I'm glad to hear that I misunderstood your position.
On the "one expert" point, I disagree that this will or should happen. If what makes one an expert is their understanding, there is nothing, except one's own abilities and situation, that keeps anyone from understanding. The information is there for many experts regardless of their professional titles. I do think there will be a confluence of practice patterns. This is similar to your assessment of the future but different on the concept of "one expert". My secondary prediction is that we're both wrong.
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RE: Whacking, Cracking, and Chiropracting - November 7, 2007 1:38:52 PM
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SJBird55
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Jon, a bar graph is worth a thousand words. I can't paste one in here to assist you in understanding what I am stating. If you have Excel, you can put some pretend numbers in to view a bar graph. First row, 2nd column: Theory; first row, 3rd column: No Theory. Second row, first column: Negative Evidence; second row, second column: -5; second row, third column: -5. Third row, first column: No Evidence; the third row second and third columns = 0. 4th row, first column: Positive Evidence; the 4th row second and third columns = 5. Create a 3D bar graph and you will easily see that both the "no theory" AND the "theory" can have positive evidence. If I were speaking of quadrants, which graphing in that way will not do, we want to target our efforts so that we practice in the top right quadrant where positive evidence exists (theory or no theory).
Proud, the problem in the states is that there is never anything on the claim for to assist with providing information with regard to clinical decision-making. Payors may not really know what is actually occurring in the clinic because "therapeutic exercise" and "manual therapy" are quite broad. As they analyze claims, they may come up with something like "manual therapy" is not effective... but they many not know WHAT the heck was provided.
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RE: Whacking, Cracking, and Chiropracting - November 7, 2007 1:58:01 PM
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Jon Newman
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Hi SJ,
From your post I'm understanding that you think someone can effectively engage in daily practice in the absence of holding any theory. I disagree. Hypothetical graphs that beg the question won't help regardless.
(edited for clarity)
< Message edited by Jon Newman -- November 7, 2007 2:11:13 PM >
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RE: Whacking, Cracking, and Chiropracting - November 7, 2007 3:17:25 PM
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SJBird55
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From: Michigan
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I'm not advocating that daily practice should be in absence of any theory. I'm advocating that in cases where there is positive evidence on the outcome of care whether there is a theory, a poor theory, an erroneous theory or no theory for the rationale for the positive evidence, the positive evidence should lead the practitioner. The "hypothetical" graph would help you to realize that there can definitely be situations on the continuum that can lead to positive outcomes - at the farthest end of one is no theory and at the farthest end of the other is full, accurate theory. Utopia would be an accurate theory with positive evidence. That doesn't happen very often though, does it?
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RE: Whacking, Cracking, and Chiropracting - November 7, 2007 4:45:23 PM
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proud
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Jon,
On the topic of "one expert". This IS very important. We need that one profession to be exceptional at self goverance.
The "one expert" concept is a must if we wish to gain some measure of control over the current "free for all" environment we have with conservative management of NMSK clients. It is simply creating nocebo effects and really poor outcomes. The concept is nothing new. If your teeth require work you see a dentist( no confusion), if you are having trouble seeing you see an optometrist( no confusion), if you need a prescription filled you see a pharmacist( no confusion).
Now ask a member of the public who they consider is the expert at treating back pain....my guess is it breaks down something like this: 50% chiropractic; 25% physiotherapists; the rest select physicians, massuers, acupuncturists, hebalist, naturopaths etc.
See the problem? The public is confused...and when there is confusion....there lives oportunists exploiting the confusion. Some Chiropractors are ethical...others not. Some PT's are ethical...others not. Allowing "experts" to live under any professional umbrella they so choose has failed...miserably. And until we can establish THE expert and allow that profession to strictly govern, there will be problems. High time our own professional journals stopped advertising for John Barns seminars etc.
Jon, I truly fail to see your opposition to this? Based on past reading, I think you tend to align with those over at the soma simple sight and the notion of being held to a standard of outcomes is off putting to that crowd. However, portions of what they will say IS in fact grounded in outcome data. Appropriate pain education...hurt vs harm etc are all established forms of treatment. So you do not have to abandon sound pain science to practice appropriately Jon. But you cannot throw a "special blend" of treatment at a patient without the data and expect to be considered "expert" of course. Makes sense to me.
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RE: Whacking, Cracking, and Chiropracting - November 7, 2007 8:06:16 PM
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Jon Newman
Posts: 1697
Joined: April 24, 2004
From: Amherst, WI
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Hi Proud,
You cover more ground in your post than the "one expert" topic but I'll try to address the major points.
"Self governance" is a different issue than "one expert". My thoughts about "one expert" are not the same as they are for "self governance.
quote:
If your teeth require work you see a dentist( no confusion), if you are having trouble seeing you see an optometrist( no confusion), if you need a prescription filled you see a pharmacist( no confusion).
These are faulty analogies. PT covers a much broader population and problem list than these specialties. If all we did was "low back pain" then you'd have a stronger argument.
quote:
The public is confused...and when there is confusion....there lives oportunists exploiting the confusion.
As illustrated in the second paragraph of your post, I think it is practioners who are first confused, not the public.
quote:
Some Chiropractors are ethical...others not. Some PT's are ethical...others not. Allowing "experts" to live under any professional umbrella they so choose has failed...miserably.
What makes you think that one umbrella will eliminate the problem? In your example the umbrella held little sway over what an individual under a particular umbrella does. Do you also envision legislating which treatments the "experts" give patients?
Out of curiosity, in your "one expert" scenario do you think there will be expert experts? If so, will it be an act of legislation that makes the expert expert an Expert or does that process only need to happen one time?
quote:
Based on past reading, I think you tend to align with those over at the soma simple sight and the notion of being held to a standard of outcomes is off putting to that crowd.
I haven't noted this attitude in ANYONE who routinely participates at Soma. If that point is important to you I'd be happy to discuss it via PM or email as it is irrelevant to the current topic and essentially ad hominem.
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RE: Whacking, Cracking, and Chiropracting - November 7, 2007 8:35:06 PM
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proud
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Jon,
You and I speak a different langauge I am afraid.
One expert makes for easier goverence. That is all.
Notice that GP's have a wide scope of practice yet are held to a standard of EBM. You will not see them using a "special brew" of anecdotal treatment for angina lets say. Clinical guidlines exist and they are held to that standard by their respective colleges. As it should be in PT.
As for the rest of your post....simple smoke an mirrors in my opinion.
And finally, call it ad hominem if you like. I have read over there and that is my impression. I am entitled to it.
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RE: Whacking, Cracking, and Chiropracting - November 7, 2007 9:10:02 PM
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Jon Newman
Posts: 1697
Joined: April 24, 2004
From: Amherst, WI
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Hi Proud,
quote:
Notice that GP's have a wide scope of practice yet are held to a standard of EBM.
Yes, using GP's would be a better analogy. PTs, like GPs, have an ethical obligation (already) to stay abreast of the evidence informing their practice. How does this relate to "one expert"? Do you consider GPs the "one expert" of medicine?
An ad hominem argument is simply an attempt to discredit someone's position by drawing attention to characteristics of the person holding that position. You did this and I pointed it out, that's all.
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