Evidence Based Rehab

Often times it is the obvious that is the most difficult to grasp or realize:






Jason L. Harris

Labels: woo, You Tube

Looking back on my first year of blogging, I noticed I liked a few posts that likely did not get much viewing exposure back then. Therefore, I plan to occasionally repost a few of these select posts from that first year. Here is the first offering.

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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.

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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 .

Jason Harris

Labels: alternative medicine, evidence based medicine, repost, woo

Rich-Mar announces the first FDA approved combination Laser/TENS unit. Because if separately one is questionable in it's effectiveness, together they must be able to cure the blind.

Somewhere Chiropractors are lining up to buy these units by the dozen.

From the release:

One of the biggest challenges physical therapists and chiropractors faced, up until now, is the fact that laser treatments were not reimbursable by health insurance,” said Douglas Johnson, ATC, EES, CLS, and medical consultant to Multi Radiance Medical. “These professionals knew that therapeutic lasers worked, but struggled with both the initial purchase of the unit and determining what to charge patients for the treatment without reimbursement. The LaserStim accessory and its unique design changes all of that. Time spent administering light therapy with LaserStim is now being reimbursed by insurance. Most physical therapists and chiropractors will see the unit pay for itself in less than one month of treatments.”

Ahh, the truth comes out. Insurance companies (rightfully, for now) won't reimburse for Laser treatment, but they do for E-stim. Well, hell, strap a couple of electrodes to the laser and call it "LaserStim" and you can now charge for it!

Labels: EBM, evidence based medicine, Fraud, Low Level laser therapy, woo

Arelease from the APTA states the NATA (athletic trainers association) has filed a lawsuit against them for "anticompetitive" activities. The main point relates to MANUAL THERAPY, specifically rib and spinal manipulation. Now, as the few of you that read my posts know, I'm a big believer you don't need 4 years of hot air and philosophy to manipulate the spine, but you do need to have an excellent background in systems review, examination skills, and a wide knowledge of differential diagnoses. Chiros have this and PT's have this, but I don't see this with ATC education. And I choose a "masters" level education, which is the "new and improved" ATC degree, to highlight this.

I make no claim that I could effectively manage the day to day sports injury needs of a sports team or walk the sidelines of a game and provide the triage care that an athletic trainer can. However, ATC's are beginning to push their limited rehabilitation education into the realm of PT, and I guess DC. This is just another example of people wanting more than they are willing to go to school and get the education for. Heck, internally we even exclude PTA's from MT courses because IT IS OUTSIDE OF THEIR educated abilities. Here is the statement from the APTA:

APTA Responds to NATA Lawsuit

The National Athletic Trainers' Association (NATA) on February 1, 2008, filed a lawsuit against APTA and the Orthopaedic Section, APTA, Inc. in the U.S. District Court in Dallas. The complaint alleges that the APTA and the Section have violated the antitrust laws by seeking to deny athletic trainers (ATCs) access to the market for manual therapy and by coercing physical therapists to refrain from educating ATCs in certain techniques. APTA's counsel is currently reviewing the complaint. APTA believes that the NATA lawsuit is wholly without merit.

Physical Therapy can ONLY be provided by lisenced PHYSICAL THERAPISTS. Not by ATC's who wish themselves physical therapists.

For more fun reading, here are some additional links:

• NATA's Letter to the APTA - laughable
• Addendum to the above letter
• APTA's letter to NATA
• NATA's Injunction Filing

What is sad, is that we NEED ATC's. They are an integral part in the healthcare field. However, they are not physical therapists and yet they not only want to act like PT's their informational pamphlets boast about how ATC can be abused for economic gains being used as PT's by physicians and hospitals:

The value of certified athletic trainers isn’t limited to the
sports field. While ATCs have worked with orthopedists and in
rehabilitation clinics for the past 40 years, they can provide
a great deal of assistance – and additional revenue – to a
hospital, physician office or clinic, whether it be a large,
university-run complex or a small, private practice.

Then from a "FACT SHEET":

1. FACT: All athletic trainers have a bachelor’s degree from an accredited college
or university. Athletic trainers are health care professionals similar to physical,
occupational, speech, language and other therapists.

Sure, and I have a Doctorate degree similar to medical doctors then. What? It's not? Somebody better tell the NATA then.

To me, it seems the NATA may be trying to convince the lay public that they are in fact physical therapists with out having to go to physical therapy school. I hope you don't make the mistake of taking your grandfather s/p CVA or your mother with a diabetic ulcer, or your uncle who is trying to recover from a heart attack to a professional with out the educational background to effectively, and possibly, safely treat them.

It one thing to wave the magic wand (ultrasound) over someone and educate them in therapeutic exercise (which I believe ATC's surely do well) it's another thing to claim to be on par with THE experts in neuromusculoskeletal evaluation and rehabilitation.

Labels: APTA, Direct access, EBM, Healthcare, NATA, woo

Ifirst want to apologize for the time between posts. I've been pretty busy at work, and have found it hard to find time to write. However, I get an "Evidence Express" email everyday from the folks over at Evidence in Motion, and today's included a link to an article from the Poughkeepsie Journal out of New York. The article was on craniosacral therapy and how proper rhythm is needed to ensure a healthy living.

Craniosacral Therapy (CST) is not new, but what is disturbing, is we know it's a bunch of hogwash, and journalist are still writing about it. For the fortunate not exposed to this lunacy, here are some of CST practitioners claims (BTW, you'll find PT's, DC's, Osteopaths and Massage therapist all using this):

1. The "founder" and his Upledger Institute states:

   "Using a soft touch generally no greater than 5 grams, or about the weight of a nickel, practitioners release restrictions in the craniosacral system to improve the functioning of the central nervous system."

2. That one can feel the craniosacral rhythms of the cerbrospinal fluid.
3. And that is is effective in treating:
• Migraine Headaches
• Chronic Neck and Back Pain
• Motor-Coordination Impairments
• Colic
• Autism
• Central Nervous System Disorders
• Orthopedic Problems
• Traumatic Brain and Spinal Cord Injuries
• Scoliosis
• Infantile Disorders
• Learning Disabilities
• Chronic Fatigue
• Emotional Difficulties
• Stress and Tension-Related Problems
• Fibromyalgia and other Connective-Tissue Disorders
• Temporomandibular Joint Syndrome (TMJ)
• Neurovascular or Immune Disorders
• Post-Traumatic Stress Disorder
• Post-Surgical Dysfunction

(Emphasis Added)
Wow! Those are some pretty broad claims. In fact, the CST claims have met all 7 of 7 of my "How to Spot Woo" post I made previously. Here are some truths:

1. Some people get better with CST. There is no doubt in this. But some people get better with magnets, with "energy manipulation", with homeopathic water, with...you get the point. The truth, though, is there is no research that shows people can get better BECAUSE of CST.
   
2. 5 grams IS NOT enough force to get movement of a cranial bone. A study by Downey and associates easily showed this.
3. Study after study shows CST providers cannot show reliability of "feeling" the craniosacral rhythm either between different providers or even within the person using repeated measures. To clarify, it's like your doctor diagnosing your heart problem by listening to your heart with a stethoscope, but at worse than chance, 2 doctors can't agree with what they hear, and worse, the same doctor hears something different when he listens a second time. Read studies done by Rogers here, and Wirth-Pattullo here.
   
4. According to a large systematic review of CST related literature, the British Columbia Office of Health Technology Assessment concluded that -
   

The benefit of craniosacral therapy has not been demonstrated using well-designed research. The available studies are of low grade evidence as rated by the Canadian Task Force on Preventive Health Care (20) ranking system, and are of poor quality when judged using standard critical appraisal criteria. Inadequacies in the studies cited above preclude any statement attesting to craniosacral therapy effectiveness.

What does John Upledger counter with? The pathetic argument that many of these snake oil salesman use:

[P]ositive patient outcomes as a result of CranioSacral Therapy should
weigh greater than data from designed research protocols involving
human subjects, as it is not possible to control all of the variables of such
studies.

Classic.

Labels: alternative medicine, cranial sacral therapy, CST, EBM, Evidence, woo