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Evidence based PT a crisis in movement

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  • #76
    Human observations are prone to biases of perception and memory. Robust studies are designed to reduce such biases. Human observational biases can be easily controlled for by intellect. Most trials fail to control for biases sufficiently. Human observational biases are still evident though, for example the perception biases seen when interpreting the results of a trial. Treat real-life experience and outputs from studies as equally valid sources of evidence, which can both be highly fallible
    Hmmm, while at surface level I accept what he says and RCT's as Ian notes often fail to tell us what we need to know, I am uneasy. Experience (as the very kind cited by Roger) also tells me that people are very prone to bias. Also he assumes that there is an exercise of intellect which is not always the case. Very few people can see themselves as they are (moi aussi) and fewer that what they have invested themselves in may actually be untrue or not as it seems. Medicine is littered - literally - with examples of this.

    Should we hold both research and personal experience as equal in value?

    Does anyone else see a problem here?

    How do we go forward?

    ANdy
    "Here is Edward Bear coming downstairs now, bump, bump, bump, on the back of his head behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there is another way, if only he could stop bumping for a moment and think of it." A.A. Milne

    Comment


    • #77
      Originally posted by amacs View Post
      ...I am uneasy. Experience (as the very kind cited by Roger) also tells me that people are very prone to bias. Also he assumes that there is an exercise of intellect which is not always the case. Very few people can see themselves as they are (moi aussi) and fewer that what they have invested themselves in may actually be untrue or not as it seems. Medicine is littered - literally - with examples of this.

      Should we hold both research and personal experience as equal in value?

      Does anyone else see a problem here?

      How do we go forward?
      And herein lies the inherent problems with the 'less-wrong' EBM, compared to anecdote and empiricism. We are on the right path, but continue to fall short of practice that is informed by science to the extent that we all desire.

      This was very apparent to me as I read study after study re: TKR and rehab. The exclusion criteria for nearly every study would exclude EVERY patient that I care for. How generalize-able, then, is the data I review?

      Meanwhile - and much to Roger's point - I see this abstract in my news feed this morning from PT Journal:

      Background The McKenzie method is widely used as an active intervention in the treatment of patients with non-specific low back pain. Although the McKenzie method has been compared to several other interventions, it is not yet known whether this method is superior to placebo in patients with chronic low back pain.

      Objective To assess the efficacy of the McKenzie method in patients with chronic non-specific low back pain.

      Design Assessor-blinded, 2-arm, randomized, placebo-controlled trial.

      Setting This study will be conducted in physical therapy clinics in São Paulo/Brazil.

      Participants One hundred and forty-eight patients seeking care for chronic non-specific low back pain.

      Intervention Patients will be randomly allocated to two treatment groups: McKenzie method or Placebo (detuned ultrasound and short wave therapy) for 5 weeks of 30 minutes each.

      Measurements The clinical outcomes will be obtained at the completion of treatment (5 weeks) and at 3, 6, and 12 months after randomization. The primary outcomes will be pain intensity (measured by the Pain Numerical Scale) and disability (measured by the Roland Morris Disability Questionnaire) at the completion of treatment. The secondary outcomes will be pain intensity, disability and function, kinesiophobia and global perceived effect at 3, 6, and 12 months after randomization and kinesiophobia and global perceived effect at completion of treatment. The data will be collected by a blinded assessor.

      Limitation Therapists will not be blinded.

      Conclusion This will be the first trial to compare McKenzie to placebo in patients with chronic non-specific low back pain. The results of this study will contribute to better management of this population.
      So, we are going to have ANOTHER study to assess the difference between a passive placebo and a movement based therapy for chronic pain? And when the MDT is improved more than placebo by statistically significant margin? What claims will be made?

      For every positive I see in a week, I see 2 negatives - and I try my best to be as insular in social media and real life as possible (it is best for my sanity)...still BS creeps in through the cracks under the door.

      Respectfully,
      Keith
      Blog: Keith's Korner
      Twitter: @18mmPT

      Comment


      • #78
        Yeah, Keith, the PTJ editors need to bone up on the research on non-specific effects and patient expectation. These passive "placebo" studies are passé (pardon the pun) given that we are attempting to establish a therapeutic relationship with a person suffering persistent pain. We know that treating pain requires entering the "third space", and to the extent an active intervention is more likely to achieve this than a passive one determines the statistical significance of a study like this.

        As an aside, I'm going to address a point that I agreed with in Kerry's piece, and it's relevant to the issue of research studies like this one Keith referenced. I've seen some less than well designed trials published in PTJ and JOSPT over recent months from research groups in South America. The dry needling trial by Mejuto-Vazquez et al (JOSPT, Sept 2014) where kappa values from referenced reliability studies were mis-cited in the introduction comes to mind. This study never should have passed peer-review. Aside from the mis-citations from previous research, the review of the reliability literature for diagnosis of trigger points- a total of one short paragraph- was far too cursory for a trial that hinges on the existence of these things.

        In his blog, Kerry implies that journal editors are too worried about impact factor at the expense of "faciltat[ing] the dissemination of thought and knowledge." It seems that some studies are getting published from areas of the world that are not as well-represented in the higher profile journals. I'm all for increasing intellectual diversity, but this shouldn't occur at the expense of rigorous peer review standards. I wonder if impact factor concerns are driving this.
        John Ware, PT
        Fellow of the American Academy of Orthopedic Manual Physical Therapists
        "Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
        “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
        be carried on to success.” -The Analects of Confucius, Book 13, Verse 3

        Comment


        • #79
          I don't see a big issue with the above RCT protocol. It looks to me like it will be a valuable addition to the literature. The protocol is structured in a way to determine if the McKenzie method has efficacy in treating CNSLBP. To determine efficacy, a no treatment or placebo control group should be used.

          We might assume that since the McKenzie approach is active it will likely show a greater effect than a placebo but, by how much? Will it be statistically significant? Or more importantly, clinically significant? I think these are important questions that can provide us with information to help determine if the McKenzie method is a useful approach in treating CNSLBP. Some well designed pragmatic trials would also be necessary to give a clearer picture of the benefits (or lack thereof) of the McKenzie method.

          More on efficacy vs effectiveness here -- http://physiologicalpt.com/2014/09/0...effectiveness/
          Kenneth Venere PT, DPT
          @kvenere
          Physiological

          Comment


          • #80
            I found Roger's post thought provoking and appreciated many of his insights. I posted the following response

            Roger, thank you for the thought provoking post. I agree with many of the insights as well as frustrations you elucidate as well as the insight that evidence based practice is not really being understood and subsequently utilized correctly. Much work to be done...

            Your post seems to inadvertently create a few false dichotomies:
            Utilizing Bio-Psycho-Social OR Biomedical/Biomechanical. Similar issues are present in the proper application of the BPS model. The BPS model is meant to FULLY incorporate the biomedical and biomechanical model (it's part of the "bio" part), but recognizes the importance of psychological and social constructs. The BPS down right is the biomedical model expanded and broadened to assess more than just a person's anatomy and physiology.

            Missing an aortic aneurysm is not a failure of the BPS model nor "pain science" per se, but rather a failure of the clinician to properly screen medical conditions and rule out occult medical conditions.

            Pain Science OR Biomedical. Similar thoughts here. The application and integration of the science of pain into the treatment of patients should never ignore biomedicine, red flags, or proper medical screening. It's inherent, and should be assumed, that as a professional you are charged with proper screening, ruling out, and evaluation.

            As you mentioned, those researching pain and the subsequent studies illustrate to us just how darn complex the individualized, lived pain experience really is. And, how many factors affect "pain." It's more than brains, but helping us recognize that PT is not just from C1 down is quite important. Yet, instead of recognizing this complexity and working to integrate understanding into practice, as you recognized, we instead make up complex treatment paradigms, classification systems, and sub-groups of responders in ways that are likely not quite valid. PT as a profession also loves to attempt classification of clinical syndromes into made up nominal pain diagnoses. Impingement, patella femoral pain syndrome, and other clinical syndromes/diagnoses come to mind. As you mentioned I'm not sure these nominal diagnoses or at times complex diagnostic constructs help us any....

            Per usual, Jason Silvernail summarizes the issue with keen insight so I will link to this must read post: http://www.evidenceinmotion.com/abou...p-deep-models/

            Some of my general thoughts on integrating evidence and research into practice
            http://ptthinktank.com/2014/01/06/me...ce-dptstudent/
            http://ptthinktank.com/2014/05/15/da...n-garbage-out/
            http://ptthinktank.com/2014/05/04/dp...al-experience/

            We absolutely must learn from humanities, psychology, and other scientists.
            Other relevant posts
            http://ptthinktank.com/2014/05/07/pr...omment-page-1/
            http://physiologicalpt.com/2014/08/1...an-deceive-us/
            http://physiologicalpt.com/2014/09/0...effectiveness/

            Some discussion happening here: http://www.somasimple.com/forums/showthread.php?t=19074

            Thanks again for your honest, straight forward critiques of what we do and the importance of modeling the WHY.
            Kyle Ridgeway, PT, DPT
            PT Think Tank |@Dr_Ridge_DPT | Google+
            "It takes a deep commitment to change and an even deeper commitment to grow." - Ralph Ellison

            Comment


            • #81
              Kenny,
              When people think of "placebo" in the way it's being delivered in this study, they are comparing that definition to what's used in drug trials. In placebo-controlled drug trials, non-specific effects of the interaction between the investigator and subjects in both groups are essentially a wash. This isn't the case in a trial of this nature. As Keith suggests, the very nature of a passive compared to an active intervention for patients with persistent pain is loaded with variables that could lead to specious conclusions.

              For instance, are they going to control for the "placebo" group participants' expectations of the detuned US and shortwave therapy? What if members of the control group have a strong negative expectation of his intervention based on past experience? Owing to the known effects of negative expectation on pain, that could inflate the mean differences between the groups resulting in statistical significance and a conclusion that McKenzie has been shown to be efficacious in a placebo-controlled trial. All that'll have been shown is that expectations of passive placebo interventions in patients with chronic LBP are highly variable.

              There's also the issue of how the time is spent with the clinician in the control group. Surely those in the McKenzie group will get lots of verbal interaction with the therapist. How will this compare to the interaction that is received by the subjects getting fake US and diathermy? Won't this increased verbal interaction have the potential to improve therapeutic alliance and response to treatment?

              I can already predict the outcome of this study. There'll be a short-term effect in favor of the active McKenzie intervention, which will level off in the long-term and ultimately show small effect sizes, if any.

              This study will cost a lot of money. Awards will be won- perhaps a Bronze Lady. Speeches will be made at international symposia...
              John Ware, PT
              Fellow of the American Academy of Orthopedic Manual Physical Therapists
              "Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
              “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
              be carried on to success.” -The Analects of Confucius, Book 13, Verse 3

              Comment


              • #82
                This is Roger’s definition of pain science https://twitter.com/RogerKerry1/stat...95899639898112

                It’s weird to me trying to discuss things on twitter, I don’t know how people do it.
                -Evan. The postings on this site are my own and do not represent the views or policies of my employer or APTA.
                The reason why an intellectual community is necessary is that it offers the only hope of grasping the whole. -Robert Maynard Hutchins.

                Comment


                • #83
                  A facebook thread:
                  Dearest Physio colleagues, friends, and critics,
                  Following numerous requests, and for the purposes of recent discussions, I am defining 'Pain Science' as:
                  "That body of scientific knowledge which de-emphasises a biological component to a person's painful experience and prioritises education as an interventional strategy"
                  Please tell me if this is inaccurate / mis-represents the notion of Pain Science as you see it, for you are much more cleverer than what I am.
                  Another:
                  Thanks to the marvellous Sigurd Mikkelsen
                  I think Kerry has done a good job of provoking conversation, and letting himself be poked some fun at at in the process without taking it personally.

                  Diane
                  www.dermoneuromodulation.com
                  SensibleSolutionsPhysiotherapy
                  HumanAntiGravitySuit blog
                  Neurotonics PT Teamblog
                  Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
                  Canadian Physiotherapy Association Pain Science Division Facebook page
                  @PainPhysiosCan
                  WCPT PhysiotherapyPainNetwork on Facebook
                  @WCPTPTPN
                  Neuroscience and Pain Science for Manual PTs Facebook page

                  @dfjpt
                  SomaSimple on Facebook
                  @somasimple

                  "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

                  “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

                  “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

                  "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

                  "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

                  Comment


                  • #84
                    Originally posted by Evanthis Raftopoulos View Post
                    This is Roger’s definition of pain science https://twitter.com/RogerKerry1/stat...95899639898112

                    It’s weird to me trying to discuss things on twitter, I don’t know how people do it.
                    Beyond me Evan, too fragmented and it feels like it is all about the 'sound bite' rather than having room to look at content.

                    ANdy
                    "Here is Edward Bear coming downstairs now, bump, bump, bump, on the back of his head behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there is another way, if only he could stop bumping for a moment and think of it." A.A. Milne

                    Comment


                    • #85
                      Originally posted by keithp View Post
                      And herein lies the inherent problems with the 'less-wrong' EBM, compared to anecdote and empiricism. We are on the right path, but continue to fall short of practice that is informed by science to the extent that we all desire...

                      ...So, we are going to have ANOTHER study to assess the difference between a passive placebo and a movement based therapy for chronic pain? And when the MDT is improved more than placebo by statistically significant margin? What claims will be made?
                      Originally posted by venerek View Post
                      I don't see a big issue with the above RCT protocol...
                      Originally posted by John W View Post
                      ...As Keith suggests, the very nature of a passive compared to an active intervention for patients with persistent pain is loaded with variables that could lead to specious conclusions...

                      ...I can already predict the outcome of this study. There'll be a short-term effect in favor of the active McKenzie intervention, which will level off in the long-term and ultimately show small effect sizes, if any.
                      Then there is the issue of what such a study actually tells us. In this review by Kerry published last year, less than half of scientific studies that are published were scientifically true.

                      Sometimes - when I read of research studies - it feels like we are simply tossing a weighted coin.

                      Respectfully,
                      Keith
                      Blog: Keith's Korner
                      Twitter: @18mmPT

                      Comment


                      • #86
                        So where do we go Keith? How do we formulate therapeutic interventions if the evidence base is that corrupt?

                        ANdy
                        "Here is Edward Bear coming downstairs now, bump, bump, bump, on the back of his head behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there is another way, if only he could stop bumping for a moment and think of it." A.A. Milne

                        Comment


                        • #87
                          I could be wrong, but it seems to me that most of us practice based on expertise (which IMO includes our own interpretation of the literature), philosophy of practice, and value system.

                          Ioannidis's 6 corollaries help when trying to assess 'best available' evidence
                          http://www.plosmedicine.org/article/...l.pmed.0020124
                          Last edited by Evanthis Raftopoulos; 05-10-2014, 05:55 PM.
                          -Evan. The postings on this site are my own and do not represent the views or policies of my employer or APTA.
                          The reason why an intellectual community is necessary is that it offers the only hope of grasping the whole. -Robert Maynard Hutchins.

                          Comment


                          • #88
                            An example of philosophy of practice would be

                            " I avoid relatively aggressive approaches to a pain problem, because they seem counterintuitive in the context of treating pain"

                            A conflicting example would be

                            " I embrace relatively aggressive approaches to a pain problem, because it seems reasonable that they can help downregulate threat response systems"

                            Couple of more examples of philosophy of practice (these may also be part of value system for some)

                            " I understand that you wish to have [massage, or that much pressure], but I don't provide that type of service".

                            or

                            "I understand that manipulation (hvlat) was helpful in the past, but I don't provide that".


                            An example of practicing based on a value system would be

                            "I really enjoy working with this individual, so I don't mind seeing him/her for a few more sessions"

                            or

                            "I really enjoy working with this individual, but I don't think I should continue seeing him/her".
                            -Evan. The postings on this site are my own and do not represent the views or policies of my employer or APTA.
                            The reason why an intellectual community is necessary is that it offers the only hope of grasping the whole. -Robert Maynard Hutchins.

                            Comment


                            • #89
                              Also, philosophy of practice and value system is often used to interpret evidence, so everything kind of blends together in a way that "makes sense" to the individual. I'm willing to bet that we tend to dismiss the evidence that does not support our already established philosophies and value systems.

                              My apologies if I'm talking excessively here.
                              -Evan. The postings on this site are my own and do not represent the views or policies of my employer or APTA.
                              The reason why an intellectual community is necessary is that it offers the only hope of grasping the whole. -Robert Maynard Hutchins.

                              Comment


                              • #90
                                Ioannidis's 6 corollaries help when trying to assess 'best available' evidence
                                http://www.plosmedicine.org/article/...l.pmed.0020124
                                I think Prof Kerry is suggesting something that exceeds those corollaries or would seek to make them redundant, I think. Haven't wrapped my head around it yet.

                                ANdy
                                "Here is Edward Bear coming downstairs now, bump, bump, bump, on the back of his head behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there is another way, if only he could stop bumping for a moment and think of it." A.A. Milne

                                Comment

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