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Letters and Responses |
What evidence do we have for anything we do in physical therapy? After reading your most recent Editor's Note (November 1999), I am not sure I understand what kind of evidence you require. Strain-counterstrain is based, in theory, on influencing the muscle spindle and shutting down the gamma gain. Is this evidence or proof of efficacy of treatment? Is it sufficient to know that the stretch reflex exists, and that in applying a treatment based on quieting this reflex, the measurable and reproducible effect of sustained, often permanent muscle relaxation is achieved? Neurological physical therapy is not my specialization, so I ask the honest question: "What proof do we have that proprioceptive neuromuscular facilitation works?"
If those "who really care about our profession" are distilled down to those who can back up by research findings everything they use in treatment or teach to others, where does that leave the patients I saw today who have been seen by other practitioners, some of whom were physical therapists, and who are progressing under my care? My questions are sincere and not meant to be antagonistic, but it is easy for Immelmann to be a purist in his ivory tower. Perhaps he needs to get his hands dirty a little more often and experience the bump and grind of dealing with real patients in the real world where research is respected but not sanctified.
I am from the high school class of ‘65 and the physical therapy class of ‘70, and I have almost 30 years of experience of bumping and grinding daily. My education spans Stanley Paris to Upledger to McKenzie, Maitland, Wyke, Jones.... I must say that in all those years no one has ever accused me of not caring about the profession or not being ethical or moral just because I don't have research to back up all or most of what I do.
I'm out here, and I do care about my profession and the furthering of education that can help patients with their musculoskeletal dysfunctions. I look forward to your answers to my questions and perhaps to you asking me a few.
Longmont, Colo
First, we need to measure the result of treatment and not assume that because we believe something should happen, it does. In addition, we must ask whether we achieved a clinical benefit. That is, have we changed something of meaning to the patient? Have we improved function? Helping our patients is why we exist; therefore, when our patients improve, we should be proud and satisfied. Even when we have a clinical success, however, that does not necessarily mean that our treatment "worked." Some conditions are self-limiting or self-resolving, many other events are taking place in the patient's environment. Without a controlled environment, we cannot isolate the effect of our treatments to show efficacy and effectiveness. This is why we need our researchers to investigate the effects of our clinical procedures, preferably, but not exclusively, through clinical trials. Practitioners should continue to use what the literature has to offer and, most importantly, to use their clinical judgment in the selection and application of interventions, especially those for which we have few data (evidence to support the use or rejection of treatments).
You also mentioned justifying the treatment because there was "a measurable and reproducible effect." I believe the only justification of such a claim would be evidence (you stated it was measurable and reproducible), but you did not supply a reference. I contend that your argument would be better served by your letting me know on what basis the claim is made. Please note that I am not necessarily taking issue with your conclusion. I am asking for evidence so that I can evaluate your claim, rather than blindly accepting it. If we respect the need for evidence and dialogue, such evaluation becomes natural.
Within your letter you credit me with remarks that I never made, particularly remarks about what practitioners should be doing and how they should be judged. For example, the thrust of my note dealt with the responsibility of those who teach continuing education or who otherwise promote methods to others. I believe that these individuals, like the manufacturers and distributors of products, need to examine whether what they are selling works. Similarly, I made the case that, before therapists spend time going to new courses, they should examine the literature for evidence—positive and negative—for the procedures they already use. Nowhere did I state that all treatments should be backed up by evidence before they can be used.
Proponents of evidence-based practice are not saying that practitioners can use treatments only when there is evidence or that they must seek dogmatic adherence to practices because of data. We are saying that clinicians have a moral responsibility to know about the evidence relating to their interventions and techniques and to consider this evidence in patient management. The ethical and moral issues arise not over whether there is evidence for all that we do, but whether we are aware of evidence relating to our actions and whether we choose to base our approaches on our own personal biases when sufficient data exist to suggest we should use a different approach.
Physical therapists, like most health care professionals, live in a world of uncertainty for most of our treatments and measurements. That is why so many of us are crying out for additional clinically relevant research. The real world is a place where we can either blindly accept the words of others or appreciate that evidence does exist and should be known. More often than not, we find ourselves functioning without evidence, and as long as we are honest with ourselves and others and take personal responsibility for our clinical choices, we will be meeting the highest moral and ethical standards. The more we need to function without evidence, the greater will be our uncertainty and, unfortunately, the greater will be the variability among therapists.
You list a lot of people who teach courses as evidence of your search for new ways of managing patients. Did those people have evidence? Had they published about the efficacy and effectiveness of the treatments they were promoting? Did Dr Upledger discuss the literature that clearly indicates that craniosacral rhythms cannot be reliably determined (if, of course, they exist at all)?3 Did the instructor of the McKenzie course discuss the research findings that indicate the McKenzie classification system does not lead to reliable measurements4 or that the use of the McKenzie system at best seems to have only a small benefit?5 You asked whether there is evidence for anything we do. The answer is yes! (See box.) There is a growing need for practitioners to understand how to easily obtain evidence, judge it, and apply it for the benefit of their patients.
| Is There Evidence? Yes! Too often, people believe that evidence does not exist. The following references are just the tip of the iceberg and are meant only to be illustrative of what we can find when we look. Vroomen PC, de Krom MC, Wilmink JT, et al. Lack of effectiveness of bed rest for sciatica. N Engl J Med. 1999;340:418–423. Holmich P, Uhrskou P, Ulnits L, et al. Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. Lancet. 1999; 353:439–443. Bo K, Talseth T, Holme I. Single blind, randomised controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women. BMJ. 1999;318:487–493. Schenkman M, Cutson TM, Kuchibhatla M, et al. Exercise to improve spinal flexibility and function for people with Parkinson's disease: a randomized, controlled trial. J Am Geriatr Soc. 1998;46:1207–1216. van der Windt DA, Koes BW, Deville W, et al. Effectiveness of corticosteroid injections versus physiotherapy for treatment of painful stiff shoulder in primary care: randomised trial. BMJ. 1998;317:1292–1296. Walker MF, Gladman JR, Lincoln NB, et al. Occupational therapy for stroke patients not admitted to hospital: a randomised controlled trial. Lancet. 1999;354:278–280. van Baar ME, Assendelft WJ, Dekker J, et al. Effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a systematic review of randomized clinical trials. Arthritis Rheum. 1999;42:1361–1369. —Jules Rothstein
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