Science =O=Research

[emad]

Hi all ;

Sometimes , I think ,from our side , insisting to apply Evidence-based technique is not reasonable , as we usually insist not to apply what the patient likes !

Take for example , in your office ,enters one patient saying please apply for me short-wave /ultrasounic or massage for my low back pain , the patient supports his view saying , i was in that pain since 4 years , and that treatement worked well.

Why not we do not apply ?Our postion is not reasonable , because there are still patiens take benefits from those techniques ,which are currently NOT supported by EBP.

Regards
Emad

[nari]

emad, that is the $64 question...
do we do what the patient wants (even if it is only short term relief) or what we know will be of much more benefit in the long term?

If we know of a more effective method, then we use it. If we don't know of anything better for sure, then either we 'give in' and rely on the placebo/anticipation/expectation response or send the patient away with education and a home movement program.

Which do you think is more honest a) for us and b) for the patient's welfare?

I do not think we are in this profession for short-term-come-back-in-three months pain relief in the context of so-called musculoskeletal causes of pain. Such goals lie comfortably in the paediatrics and neuroRehab context.

Nari

[emad]

Nari :

Science OR research is very strange ,it does NOT go in one /straight way .

How short wave come to practice ? Did not it come cupported by research in that day ? Did not these companies support that method with research then ?

Then we come TODAY , to read ultrasounic is not effective ,further more it detiorate the nerve and pain ?By research also ! Crazy research :embarasse :rolleyes: :confused: :confused:

Anyway , since 3 days , i have met a woman of 40 years with sciatica , a physiotherapist treated her using stretching the sciatic nerve ( SLR ) several times passively ,and using very aggressive movement of the limb , i saw him ,sometimes while he applies , then he travelled Kuwait , she came back to me after 2 month, i refused to apply those stretching , as i know this will put more stress on the sictic nerve ,leading to more sensitivity ,,,She said to me NO , the previuos therapy was better , however it is not reseach-based ,it worked .

I think the main point here ,is not applying evidence-based or NOT , the main point is the patient convinved he/she recevied the treatement .

Regards
Emad

[Diane]

>How short wave come to practice ? Did not it come cupported by research in that day ? Did not these companies support that method with research then ?

I can't answer this portion of your thought precisely or completely Emad, but perhaps I can shed a little light on it... shortwave, ultra sound etc, everything we think of now as ancient electrotherapy, was invented in the early part of the last century by companies who expanded into the market by using findings from war technology and science, mostly European. US is from Britain as I recall. (I mean early, WW1, 1914-1918.. )

Electricity was a brand new thing at that time, electrical machines to treat people was based on brand new technology, it was all seen as good. PT generally (like most manual care professions) has conservative values; although it readily welcomes in new things at one end of itself it doesn't like to let them go at the other. For other professions the conservatism is demonstrated as not liking to let go of outdated concepts; in PT it often manifests as not liking to let go of outdated treatment devices! I think we can say for sure nowdays that outdated treatment concepts keep our profession as full of ballast as all the equipment used to!:D

Another marker on the trail here is the fact that PT was a profession that sprang up out of army culture. So the companies had a very easy market for their stuff. Sell the army back stuff based on research done in some other part of the army. That's how PTs in the 30's in every country pretty much, ended up with electrical stim machines (e.g., built to deliver exact quantities of sinusoidal current, etc.) built by reputable European firms that were almost if not exactly identical to those used to deliver torture during WW2 and after. Not a pretty answer, but I don't think the tracks are deeply buried at all.

[Bas]

Emad, don't forget that what was considered "good research" in the early days of physical modalities, consisted mostly of working theories, based on rather primitive assumptions on human physiology - very little true research was done. That is still the case for SWD. Assumptions and extrapolated effects are the best you can find.
With regards to the patient asking for "A" or "B" modality - because it "worked" - I don't have them. With regards to the violence of a technique; my response is "I don't work that way - I have found it is maybe effective for a while, but more profound changes are found with softer work" or something like that. If they still want the 'other" stuff - not in my clinic, sorry.

[JaneS]

Emad,
I spent some time explaining my ideas on passive treatment on NOI, in answer to your question. I pressed a key, lost the content and decided to read SS instead. You have actually agreed that evidence-based treatments do not always solve the problem - you gave an interesting example.

Nari,
I'm not sure that the best choice is active OR passive. My original point was that I don't think passive treatments are always given a fair go in clinical trials. They are often tested against controls on medical treatment only, no treatment, placebo or optimal active treatment/treatment combinations. Finiss & Bendetti (2005) wrote that the placebo effect could be used as a useful tool with some patients. An overall active programme with a passive component still requires participation and activity by the patient.

From recent study, I have read about 5 papers (4 since 2002) in which a passive component was combined with an active (education-psych) component in a deliberate way. Between 30-50% of subjects required the active component alone. However, most of these papers showed that about 30-50% of the remainder benefitted from a combined active + passive programme.

Taking Emad's patient, how about starting the education process while applying treatment for part of the session?. Then demonstrate some exercises and send the patient home with a short programme. This would be built on in the next session - increasing the time spent in activity/education and decreasing the passive component.

As I understand it, EBM is the judicious use of evidence in the treatment of the individual patient. The application is up to the therapist. (Hopefully most will use their heads and not their hip pockets)

Jane

[emad]

Hi Diane :
Welcome Bas:
Hello Jane :

Diane ,The History of electrical therapy ,seems, emerged from Britain as you stated , how physio would be now if the Germans ?japanese won the war ? I think the issue would be different ,no doubt .

You are absoultely right , regarding the industrial revoluation at that time was so bretty , that the human being liked every electrical thing in life .Compare it currently with making every thing digital and computerised even physio affected ,and contuined the process making every thing digital .Last month , the Hospital where I am working bought an Ultrasound apparatus digital and computersed made in japan ,for around 17000 pounds in our currency which equals 3000-4000 US $.I signed before buying that apparatus to accept that it will benfit patients , i can NOT say NO .The month before it , in my town ,s hospital the political leader of the town (the Head of the government in my town Mayer here ) entered the physio departement ,met me , asked me directly why this depatr has no patients ? I replied him because of patient culture ,and physicians who do not referr , He asked me How about buying new equipments ??I replied basing my response on Evidence-Based Practice We do not need equipments , he said are you sure ,i replied yes , i am sure .He was so sad from my reply ,he said I am not cooperative ! This is a sample from the society ! What do we expect from this culture ! No progress !

Let us move to doctors who are sometimes our patients , One day the Head of the Surgery departement had knee pain , He asked me to apply Short wave ! I tried to speak to him about science and research supproted techniques ! He did not listen to me ! what are we expect from simple people ?they will ask us to do ultrasound and short wave , and we have to do that ! this isa the right .

Bas :

I tried to find appropraie defination for Evidence-Based practice ,now to give you a link but i failed , any way ,the point which i am trying to say is that Evidence_BP is not only research , it includes also clinical expertise , we can not skip over our experience and patient ,s experience which is the most important ,it affects the patient s cortex .Why not i do not apply short wave ?if it is the patient s evidnce .

Jane :

I do not dismiss passive therapy completely , i do apply passive neurdynamics ex , and mobilisations accessory .Good point ,to apply education while the patient is under short wave /infra-red , you caught 2 birds with one stone , you satify the patient .Extremly important the patient leaves your clinic with a satisfied imperssion .


Direct Question :

Will any one apply certain technique which is ruled out by research ,but is supported by patient s experience and therapist experience ?

For me , i will aplly it , i am more practical than theortical !!!!;) :confused:

Regards
Emad

[bernard]

Electrotherapy is not an English invention!

[nari]

Jane,

I agree that EBM/EBP is not to be slavishly followed; there isn't much hard evidence around anyway which indicates without doubt that a particular technique for a particular condition is superior to all others. Too many other factors to consider, like the subtle influence of the therapists, expectation and other things.
The placebo response is present in whatever we do and whatever we say; so is the nocibo response. We can enhance it, and make the most of it, but I am not very comfortable doling out electrotherapy (as an example) purely for placebo reasons, and I don't do it. When I say 'passive' I usually mean passive mobilisation and electrotherapy; neither of which the patient can take part in. Neurodynamics is different; it is a Rx on its own, and passive testing can slide very neatly into active participation.


emad,
If you use a technique for which there is no evidence that it works, but you get good consistent results - then either something else is causing the good outcome or the technique in the studies was not done appropriately. Many PTs do not use neurodynamics effectively as a Rx..too fast, too zealous and too many repetitions. I think one is justified to use a technique that is 'out' of the EBP circle, along with education and just being rather nice to the patient...:)


Nari

[Diane]

Bernard is quite right. The invention/use of electrotherapy is widespread, but mostly western/European. (I didn't realize electrotherapy was considered part of "energy medicine." Yeeks!)

Anyway, here is a paper on the origins of ultrasound I found.
http://www.ob-ultrasound.net/history1.html

The 1940s saw exuberant claims made in some sectors on the effectiveness of ultrasound as an almost "cure-all" remedy, abeit the lack of much scientific evidence. This included conditons such as arthritic pains, gastric ulcers, eczema, asthma, thyrotoxicosis, haemorrhoids, urinary incontinence, elephanthiasis and even angina pectoris! Cynicism and concern over harmful tissue damaging effects of ultrasound were also mounting, which had curtailing consequences on the development of diagnostic ultrasound in the years that followed.

The article doesn't mention Britain specifically. Maybe the books I found in the PT library in The Center for Rehabilitation in Winnipeg Manitoba as a green intern, were Brit biased. Anyway, I had to write a paper on something to graduate, so I researched ultrasound. The books I drew from mentioned ultra sound having been researched for its potential as a possible weapon of tissue destruction. How much would it take to kill a goldfish, a mouse, a goat tied to a stake, etc.
(Later (much later, 1980's) I read of it being used in the British army to take out eardrums on prisoners (Irish) as a form of bloodless markless torture. These reports were no doubt biased, coming as they did from the mouths of the prisoners themselves, those who survived to end up eventually released.) I'm sure official versions of events contain absolutely no reference to any such thing...)