Evidence Based Rehab

Students from the University of Regis attempt to spread the knowledge regarding the Clinical Prediction Rule for SI manipulation. Fairly corny, but it gets the point across. Appears aimed at the clinician more than a prospective patient.

Are you manipulating your patients that fit the CPR? Change is difficult, but must be made to continue evolving as clinicians and providing the best care known (friggin state of Iowa and their collusion with "Palmerville")

Labels: clinical prediction rules, EBM, Low back pain, manipulation, Mobilization, physical therapy

The public has been exposed to the media over hyping (and misrepresenting) a study that finds acupuncture to be more beneficial than "western medicine". I was first exposed to this by an article on MSNBC entitled "Acupuncture - real or fake - best for back pain." Emphasis added.

Let's take a closer look. Here is a link to the full text. Luckily, this study, and the reporting of it, seems to be recieving great analysis and coverage. This includes Orac over at Respectful Insolence; Dr. Steven Novella's NeuroLogica Blog; and Dr. Ben Goldacre at Bad Science. These two are more intellingent than me, and, most importantly, are able to express themselves better. Please take the time to read their posts. Especially Orac's.

I would just like to highlight a few problems with this study. Understand, though, most studies have flaws and that does not mean they are worthless. However, these flaws must be known because they greatly effect how a study can be applied to you/me/us.

1. This study, as designed, is wholly unreproducible. Why? The "conventional treatment" group was not controlled (well). Some received all, some, one, etc of the "allowable" conventional treatments. Maybe acupuncture is a cure all, maybe not. However, another study using the same methods, cannot be done because the conventional treatment group can not be reproduced.

2. The inclusion/exclusion criteria eliminated the vast majority of patients we see (and for those reading, what you have). Therefore, cannot be applied to much of the LBP population. Orac argues this point well:

One point that leaps right off the page is that the patient population studied had had chronic low back pain for at least 6 months and, based on that duration and the patients' willingness to try acupuncture, we can reasonably infer that their pain probably wasn't responding particularly well to conventional therapy. This makes it unsurprising that the reported response rate in the standard therapy group was so low, given that it was just getting more of the same treatment.

3. There was no blinding. All the participants knew what they were receiving, and, presumably, the same practicioner was providing the "real" and "sham" acupuncture. Although is both the real and sham acupuncture did just as well...does that mean that all acupuncture is sham or that any needling is real acupuncture? Hmm..... In my opinion this opens the door to rater bias and a very large placebo effect (hmm, the 'I'm receiving a "new" treatment' group does better than the 'I'm receiving the same crap that hasn't seemed to work in the past' group).

What to make of this study then? Those with chronic LBP not linked to any known causes (sciatica, DDD, OA, Surgery, etc) that "conventional" treatment has not worked, improved with "shamish" acupuncture compared to the same old crap. Not quite the same as "Best for back pain".

Labels: acupuncture, alternative medicine, EBM, Low back pain, physical therapy

I just finished reading a guest editorial by Robert Wainner, PT, PhD and Julie Whitman, PT, DSc regarding first line interventions for hip pain in the most recent Journal of Orthopaedic & Sports Physical Therapy. Their discussion points to the trend that hip pain, especially OA, is treated in the order of 1. Drugs, 2. Surgery/invasive procedure, 3. Physical Therapy.

Why is PT last? Especially when there are known PT interventions for hip pain that work well. The authors point our that research on exercise for hip pain is not as broad as the knee; but some recent hight quality studies (which include those published by the authors) lend us the ability to form a practice guideline as to treat hip pain. This includes manual physical therapy (mobilization/manipulation) and exercise as the primary exercises.

The general public reading this should also demand (yes, demand, lol) from their primary care doctors that PT is the first line intervention for their hip pain. On our end, we (as PT's) must stay abreast the on current best evidence for treating hip pain - again, mobs and exercise as primary treatment - and APPLY this treatment. We must change and adapt as clinicians.

If you have questions about your hip pain, please as your doctor to refer you to a PT, use the APTA's "Find a PT" tool, or I can try to answer any comments you leave.

Labels: APTA, EBM, Evidence, exercise, Hip, Mobilization, OA, Osteoarthritis, physical therapy

FRiday fun again. Hope everyone had a great week. Thank you for taking the time to read my rants and ramblings. I'm planning on watching 300 for the first time tonight and thought I'd prepare by watching the trailer. Enjoyed it so much I thought I would share it with you.

Labels: Fun

I
occasionally receive comments from readers. My post on the traction machine called the DRX 9000 is a good example of many different comments left. I have recently began receiving many "Anonymous" posts that attack me directly or are far off subject. Examples being "Anonymous" drawing up arms to have me prosecuted for libel and this most current unpublished one:

Why won't you post all comments?

That is what a blog is for?

You post "under investigation" about your competition, but you won't post factual occurrences about your own profession?

Why would this be?

Please post the recent submission about the "fraud" that has been going on within the Physical Therapy profession.

Must keep an educated and unbiased look at everything :)

Until then, this is just a biased blog toward your own advancements, that is all that it is.

My reply? If you don't have the balls to not post anonymously and do so to attack me or make comments not relative to the original blog post, I will unilaterally reject the comment. I have ok'd every opposing view that stayed on subject.

Oh, and yes, this blog is for my advancement and physical therapy in general advancement. I make no hidden agendas in that right.

Conclusion, stay on subject and I have no problem publishing your comments.

Labels: Chiropractic, Direct access, DRX 9000, physical therapy

Ihate "health" products being pushed on us simply with anecdotal evidence and testimonials. One of the newest fads is 'Whole Body Vibration'. The claim is that exercising on this vibrating plate significantly increases your strength versus doing the exercises alone. There is very poor, and limited, evidence for this. For a good overview, please read Sal Merinello's excellent synopsis of the evidence over at The Healthy Skeptic. Below is a brand new journal article on this fad in regards to impact on older men over a 1 year period.

: J Gerontol A Biol Sci Med Sci. 2007 Jun;62(6):630-5. Links

Impact of whole-body vibration training versus fitness training on muscle strength and muscle mass in older men: a 1-year randomized controlled trial.

Bogaerts A, Delecluse C, Claessens AL, Coudyzer W, Boonen S, Verschueren SM.

Division of Musculoskeletal Rehabilitation, Katholieke Universiteit Leuven, Tervuursevest 101, Leuven, Belgium.

BACKGROUND: This randomized controlled study investigated the effects of 1-year whole-body vibration (WBV) training on isometric and explosive muscle strength and muscle mass in community-dwelling men older than 60 years. METHODS: Muscle characteristics of the WBV group (n = 31, 67.3 +/- 0.7 years) were compared with those of a fitness (FIT) group (n = 30, 67.4 +/- 0.8 years) and a control (CON) group (n = 36, 68.6 +/- 0.9 years). Isometric strength of the knee extensors was measured using an isokinetic dynamometer, explosive muscle strength was assessed using a counter movement jump, and muscle mass of the upper leg was determined by computed tomography. RESULTS: Isometric muscle strength, explosive muscle strength, and muscle mass increased significantly in the WBV group (9.8%, 10.9%, and 3.4%, respectively) and in the FIT group (13.1%, 9.8%, and 3.8%, respectively) with the training effects not significantly different between the groups. No significant changes in any parameter were found in the CON group. CONCLUSION: WBV training is as efficient as a fitness program to increase isometric and explosive knee extension strength and muscle mass of the upper leg in community-dwelling older men. These findings suggest that WBV training has potential to prevent or reverse the age-related loss in skeletal muscle mass, referred to as sarcopenia

The results show NO DIFFERENCE between groups; but, the authors make the conclusion that

"WBV training has potential to prevent or reverse the age-related loss in skeletal muscle mass..."

Huh? I guess that is true if general exercise does (which is true). But it doesn't do it any better and at a greater cost and inconvenience. Look for the manufacturers to post this on their websites as "evidence" that WBV training prevents muscle mass loss!

I say: Buyer beware!

Labels: alternative medicine, EBM, Evidence, exercise, fitness, outcomes

Have you taken your medicine today? Funny video poking fun at our current culture towards prescription drugs.

Labels: Fun

Found a brief PR article on lumbar stabilization by Physical Therapists. It is from ADVANCE magazine and the article can be found here. It appears directed at nurse practitioners, which is an important audience for us as more and more of family practice is being handled by "second tier" providers.

Maybe something that could be added to you "packet" of general information one could provide to your referral base.

Labels: Direct access, education, Low back pain, physical therapy, physicians

After many question from my patients and the general public regarding "alternative" treatments (e.g. magnets, craniosacral, dietary supplements, etc) I decided to sit down and write up an educational handout to summarize how to approach evaluating treatment options. This includes treatments in so called "Alternative Medicine" and main-stream medicine alike.

I am very concerned that many alternative treatments are blatant attempts to take advantage of persons in desperate situations. Such as end-stage cancer and progressive disease processes like arthritis.

Below are some ideas on how to approach decisions about "new" therapies to allow you to maximize your potential gains and to protect your money from those offering up only a big handful of woo.

---

EVALUATING INTERNET MEDICAL ADVICE

Jason Harris, PT, DPT

Our modern internet has opened the door to a vast arena of medical advice and information. With this information, it is important to critically evaluate the information and the author’s credibility. How does one pick between credible and worthless? It can be hard, but I will outline a few rules for judging the value of the information you are reading.

I suggest you look for "Red Flags" while researching medical information on the internet. In medicine "Red Flags" are signs and/or symptoms that warrant immediate attention as they indicate a potential life threatening situation. I will use the term to indicate immediate problems with information that is being evaluated.

"RED FLAGS":

1. Any site that use the terms "alternative", "holistic", "integrative", "natural", and/or "miraculous" (Barrett). The vast majority of websites using these terms should replace them with “unproven” and/or “ineffective”. They also tend to push Herbs, vitamins and supplements. Do not trust a salesman to tell you the whole and complete truth. Their job is to sell you the product.

2. Claim large effect on symptoms with out side-effects. Causing a large change in body function (or dysfunction) has a cascading effect that leads to known side-effects and occasionally adverse reactions. No side effect most often indicates such low doses as to have no real effect.

3. Claim that a treatment can cure multiple problems/pathologies. Nothing can, or ever will, cure your shoulder pain and skin melanoma.

4. Claim that everyone will experience the same positive results. Humans are not all the same. Disease processes are complex and include multiple organ systems to varying degrees. Due to this, you cannot expect all to respond the same way or to the same degree. This is why well run clinical trials are essential. Which brings us to the next point…

5. The use of testimonials as sole proof that treatment works. A positive experience one person has cannot be generalized to anyone else. This is a complex topic as we rely on recommendations and advice from our neighbors to function efficiently in society and these salesmen attempt to take advantage of this.

6. Person is touted as a “Guru” with many impressive sounding “credentials”. Often claims are made that your problems can only be cured by the seller. Often it is because of some procedure or test named after them that only they can do. In the end, only they can do it because there has been no published research to support or refute it’s ability to do what it is purported to do. Also watch for the use of “Dr.” when referring to this guru and/or unusual credentials (e.g. not common known credentials such as MD, DO, PhD). The use of the doctor title is an attempt to make the person appear more authoritative then they are.

7. Must buy to see results. Any reputable treatment/product should have peer-reviewed published literature that shows it can do what it claims. You should never have to first buy something to know or experience how it works.

Medical information from the internet must be reviewed wisely and used as a supplement to the advice a trusted healthcare professional has given you. When in doubt, bring the information you have found to your MD, DO, or PT and discuss it with them. These “red flags” are a good start to filtering out the majority of bad from the good.

Works Cited

Barrett, M.D., Stephen. " How to Spot a "Quacky" Web Site." 06 September 2006. Quackwatch. 7 July 2007 .

Labels: alternative medicine, Chiropractic, education, Fraud, Low back pain, physical therapy

Well, I'm back from my 4,000 mile drive across the US midwest and northwest. Had a great time seeing family and visiting new towns and areas of the US. Very beautiful and often time spectacular. Today I will introduce a short series on the history of post World War I Physical Therapy History. I feel it is very interesting to see our roots and understand why some aspects of our profession are the way they are.

The vast majority of the information presented comes from an article written by Beth Linker in the Journal of Women’s History, Vol. 17 No. 3. The first passage comes from 1922:

...women leaders of the American Physiotherapy Association (APA) invited Ray Lyman Wilbur, then president of the AMA, to give the keynote address at the national physiotherapy conference. APA president Dorothea Beck enthusiastically introduced Wilbur to the stage, assuring him that it was the goal of her association to “give the medical profession a band of trained women whose ideals, personality, and technical training are all that the physicians and surgeons of the American Medical
Association can wish.”
The APA’s congenial relationship with Wilbur and the elite men of the AMA complicates the typical historical narrative of professional antagonism
between the sexes during the 1920s. Physiotherapy represents a different kind of female professionalism—one that concerned itself more with achieving autonomy from other white–collar women than it did with gaining independence from white–collar men. Other female–dominated health occupations that arose alongside physiotherapy during the war, such as occupational therapy and dietetics, drew support from medical men. But as occupations steeped in the womanly spheres of arts, crafts, and home economics, these other professions also achieved legitimacy through the backing of women’s charity networks. By contrast, physiotherapists did not seek support from women’s clubs or female associations for professional uplift; rather, physiotherapists legitimized their profession almost solely by association with the medical profession.

We see early on that the PT profession banked it's success on allowing themselves to be partially "controlled" by the AMA. We have been fighting ever since. Where professions like massage therapy, ATC, DC's fought for legitimacy from public opinion, PT's have become, possibly, forever entangled with the AMA.

This has allowed for greater legitimacy in the health care world, but an inexplicable denial of autonomy by our past "parents". With this, it may be easier to "invent" a new musculoskeletal profession and become truly autonomous then ever cut the control lines from the AMA.

Labels: APTA, education, history, physical therapy