Evidence Based Rehab

Here is a follow up to the Clinical Prediction Rule for Lumbar Manipulation video I posted on a while back. Again, this video is presented by Physical Therapy Students hoping to educate the rest of us on the best treatment choices for our LBP patients. Enjoy!

Labels: clinical prediction rules, CPR, EBM, LBP, Low back pain, stabilization

While I try to stear clear of blogging on the US vs. Them, PT vs. Chiro debate (although my look at the use of the DRX9000 seems to be viewed by chiros as an assault on them), the underhanded way that profession is trying to "claim" manipulation in my state has brought this post out of me.

I want to first comment on how the Chiro profession is handling itself in Nebraska in regards to the PT profession updating our practice act (which dated back to the 1960's IIRC). Their must be respected powerful lobby was threatening to hold up this new legislation because the new act included language about the use of mobilization and manipulation (these are one in the same to the PT profession). "Oh no you don't" the Chiros exclaimed. They pulled out the old very false but effective crap about no having the training or skill to do (hmm, what was that I was learning in PT school then???) High Velocity Low Amplitude (HVLA) manual therapy. And, like PT's always do, we repented and asked the Chiros what we need to do to fix it. "We'll compromise" they offer.

So manipulation was crossed out and "Grade V mobilization" was added (again, in PT, manipulation and mobilization are one in the same). So, the bill is passed (will hold off on the commentary about Orthos objections to the use of "Physical Therapy Diagnosis"; Orthos and Chiros objections to "direct access" even though we've always had it by omission and no one has died - GASP!; and the school systems wanting to bill the government for PT despite providing care with untrained aides). Fast forward a year, and as the new practice act proceeds through it's many steps to fruition - A practice act is just a guideline, and specific rules and regulations need then to be developed from it - Chiros are back shouting "hold on!". We changed our minds, we object to "Grad V mobilization" cuz we say you can't do it. So it's back to expending money, time, energy, and sweat to again fight for what we've already attained. So, the Chiros back off with a knowing smirk of "we'll be back again".

The second item that brought me to write this was a great post by Panda Bear, MD entitled "Stealth Medicine and Other Topics" railing on Chiro's attempt at backdooring into becoming pediatric primary care providers. As Panda Bear quotes them:

“The doctor of chiropractic does not treat conditions or diseases.” Says so right in their mission statement. But then a little further down it ascribes complaints in every system to our old friend the subluxation and promises, by judicious adjustment of the pediatric spine, to allow the body to express a better state of health and well-being.

Imagine that. Promising one thing and practicing the opposite. Sounds familiar to me. Orac at Respectful Insolence and Eric at Evidence In Motion have both commented on a visited this particular post (Damn, I am slow on the uptake I guess). I'll quote Eric as a nice summary to all of this:

For those non-physical therapists reading this, it may be timely to point out that what IS in our scope of practice is all sorts of manipulative therapy. That's right, the specialization area of Orthopaedic Manual Physical Therapy is one where the physical therapist is equipped with both the tools to manipulate the spine or peripheral joints AND develop a comprehensive, integrated program of neuromuscular modalities for orthopaedic conditions.

For an excellent comprehensive look at the history of PT vs Chiro, the arguments analysed and what is most likely behind Chiro's fighting PT's over manipulation (hint: it's not really patient safety. Ok Hint #2: It starts with "M" and ends in "oney") click here.

Labels: APTA, Direct access, DRX 9000, education, manipulation

Ihave been meaning to blog on the results of a Lancet article finding neither spinal manipulation or NSAIDs are effective on low back pain. However, Eric from NPAThinktank beat me to it with a post on Evidence in Motion's blog. It is very well done and thought out.

The key point we must all understand, is that the population tested was a heterogeneous group of low back pain sufferers. Despite the mounting evidence, no sub-grouping of patient's was done. Predictably, then, to significant results were found. I don't care how many low back pain studies are done, if no treatment based classification is used, you will not find significant results.

Eric quotes Dr. K. Shepard using a great analogy for this. I post it here for your convenience:

A study that randomly assigns patients with low back pain to various conservative treatment protocols will produce the same results as a study that randomly assigns patients with abdominal pain to undergo appendectomy, cholecystectomy, or exploratory laparotomy. Neither study makes any sense.

Our hope in the rehab world is that the referral sources also have the great evidence of treatment based classification and the dramatic effects of lumbar manipulation on the right sub group of low back pain patients. Please read Eric's great post.

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

Iseem to be on a comic kick of late. But, there sometimes isn't a better way of expressing an idea then from the pen of a comic. Dilbert has always been a favorite of mine, and Scott Adams recently published a great comic illuminating the problems with the public relying on an - often times - ignorant journalist to provide them with an understanding of research. Enjoy! I did.

Labels: ignorance, media, Research