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Editor's Notes |
jules-rothstein@attbi.com
The 1956 Hitchock film The Man Who Knew Too Much featured a Doris Day song so saccharine-sweet that the very memory of it makes me want to increase my insulin levels. In the song, poor Doris keeps asking questions—of her mother, of her teacher, and of her sweetheart—about what will be. Better at keeping secrets than the CIA, they all tell her:
Que sera, sera,Whatever will be, will be;
The future's not ours to see.
Que sera, sera,
What will be, will be.
I don't think so! Certainly people don't manage their money with such a cavalier attitude, and God help them if they take that approach to their health. Apparently the health care community finally has learned that "what will be" does not have to be; hence the explosion in preventive medicine, an area that is relatively new to physical therapists. Like our colleagues in medicine, however, we often engage in activities that do not necessarily alter what will be. In other words, despite our interventions, which may seem quite logical, we cannot always be sure that our actions really prevent anything. Until we have longitudinal studies, we must depend on best arguments, arguments that often are founded on biological plausibility or psychological likelihood. We have little choice until there are data.
If Livingston and Evans (who wrote the Doris Day song) were right about "what will be, will be," we would not be dieting, exercising, taking cholesterol-lowering drugs, or engaging in a variety of activities to prevent pathology as well as primary and secondary disability. As a society, perhaps our problem now is that we think we can change too many things, and we are uncertain, in the absence of evidence, what things we should focus on and with what resources.
The same issue is relevant when we care for our patients. "Prognosis," according to Merriam-Webster's Collegiate Dictionary, is "the prospect of recovery as anticipated from the usual course of disease or peculiarities of the case."1(p931) The dictionary fails to note that prognosis also is often what establishes (and enhances) a health care professional's credibility. As a young physical therapist, thanks to my ignorance and the lack of a body of published data, I usually would offer a two-word prognosis: "It depends." If a patient asked when to expect full range of motion, I might say, "It depends." If a persistent patient asked what it depended on, again I might deliver sage wisdom: "It depends on a lot of things." Only the patient's persistence determined how long I was allowed to sputter ambiguously.
This month we see some researchers focusing on prognosis, a key component of the patient/client management scheme put forth in the Guide to Physical Therapist Practice.2 In the past, prognosis often has been based on the word of a so-called expert, and often that is valuable; however, if the prognosis turns out to be correct, then it is verifiable. Consider the personal suffering, both physical and psychological, that occurs in children or adolescents and their families following traumatic brain injury (TBI). False expectations don't help. Thanks to Dumas and her colleagues (pages 232–242), we now have some initial data on the predictors of recovery of ambulation in this group of patients—arguably one of the most difficult groups for which to predict outcomes.
Considerable time and resources are used to assist children and adolescents with TBI. Much of those resources are funded by overtaxed insurance systems and supported emotionally by families already traumatized by the patient's initial injury. Knowing more about "what will be" not only allows for more effective treatment, it also allows therapists to think about the possibilities of altering predictors and, therefore, changing the future. Correlational studies such as that of Dumas and colleagues do not suggest causality; however, they do provide fodder for physical therapists to use in considering new approaches to care, approaches that can be tested in clinical trials. Studies of prognosis can be powerful and are much needed.
Werneke and Hart (pages 243–254) address another aspect of prognosis. No area of physical therapy sends patients, payers, and therapists alike into paroxysms of confusion more than the management of low back pain (LBP). If ever there was a need for prognostic indicators, it would be in this area. Werneke and Hart attempt to build on the Quebec Task Force Classification (QTFC) in determining how to use clinical data to predict rehabilitation outcomes and eventual work status for people with LBP. Their work adds to a growing body of knowledge with which every physical therapist managing people with LBP should become acquainted. The answer "it depends" needs to pass into history.
The theme on prognosis continues in this issue with a Research Report involving patients with spinal cord injury. Many physical therapists believe that certain modifications of wheelchairs—to improve balance, for example—would increase seating pressures. Maurer and Sprigle (pages 255–261) point out that this belief is not necessarily true. The predictions that we have been offering people with spinal cord injuries appear, at least for this case, to have been unwarranted. This should not be surprising, however, because these predictions were not based on evidence.
Many areas of biomedicine require better data for making prognoses. National transplant lists, for instance, are based almost exclusively on what would happen if the patient did not receive a new organ. In health care rationing, we anticipate, and fear, that prognosis once again will play a role in who gets care and who does not. As physical therapists, not only do we need to know our literature on prognosis, but we need to acquire additional evidence, particularly when we want to change prognoses through the use of preventive intervention.
"What will be" may have to be, but then again, it may not. Ironically, in the song, Doris Day talks about having children of her own, and how she too will tell them, "Whatever will be, will be / The future's not ours to see." With all the sarcasm I can summon, that's really helpful. At best, such an attitude allows only for random planning—and chaos. The good news is that the future is ours, not only to see, but to modify.
References
This article has been cited by other articles:
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  D. J Smyntek, H. Dumas, S. M Haley, D. Aldrich, and D. P Hunt Use Evidence Cautiously Physical Therapy, July 1, 2004; 84(7): 665 - 667. [Full Text]
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