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Cervical Manip and Side Effects

I have attached an article that just came out in Spine related to the adverse side effects of manipulation and mobilization of the cervical spine associated with the UCLA study. As expected those receiving manipulation were more likely to experience adverse side effects. In addition, moderate to severe levels of disability was associated with adverse neurological symptoms. The conclusion: Clinicians should be conservative about applying cervical spine manipulation to their patients.

Josh
Download UCLA_risks_manip.pdf

Patient Satisfaction Verus Treatment Effect

One our of colleagues, Dr. Steve George, just published a nice paper characterizing the ability of a particular questionnaire item assessing patient satisfaction to distinguish between satisfaction with treatment effect versus satisfaction with treatment delivery after physical therapy treatment of low back pain. The findings suggest that patient satisfaction with symptoms is weakly associated with other satisfaction items and more related to self-report measures of treatment effect. The results remind us that patient satisfaction is a multi-dimensional construct and that a patient being "satisfied" with care may have little to do with whether the patient is actually better.

Steve, feel free to comment on any particular issues you think might be pertinent for the practicing clinician based on the findings from this study.

John

Download george_arch_phys_med_rehab_2005.pdf

Translating Research to Practice

Allan Jette's May editorial (Phys Ther) is excellent and speaks to the issue most readers of this blog care passionately about: translating the evidence we have (verus that which always seems to be in motion) to evidence in practice.

Download EditorialJetteEBPPhysTher2005.pdf

Ad libitum

Link: Ad libitum.

Resistance to Evidence-Based Medicine Lately I have been encountering (or noticing more) a reluctance on the part of many physicians to accepting that evidence based medicine is a good thing. Theres quite a bit written about this. Physicians are resistant to accepting EBM for several reasons: 1. Many feel threatened that with EBM they will not be allowed to practice the way they want to practice - most physicians have a strong sense of autonomy. 2. They may feel that EBM is a tool that others will use to enforce 'recipes' on how to practice medicine (the "It's cookbook medicine" argument). 3. Some feel that each patient encounter is unique and only the physician is able to judge in that particular context what the best treatment is for his patient. 4. Many docs are unfamiliar with the concepts and skills required to practice EBM. This leads to fear of the unknown, which is one of the strongest fears anyone can have. 5. Misconceptions about the nature of EBM are common. 6. Most physicians do not have the time to devote to searching and appraising the literature. 7. Patients do not demand that their doctor practices according the evidence and not just based on opinion, habit or out-dated information. 8. The "medicine is an art, not a science" argument.

# posted by LMF @ 11:39 PM 0 comments
Monday, June 20, 2005

Essential Tools for EBM
I had previously listed two essential tools to practice evidence based medicine:
1. A healthy sense of skepticism.
2. An understanding of the concept of probability.

Here are some more:
3. A belief that systematic observation yields the truth more reliably than unsystematic, anecdotal observation.
4. An ability to deal with, and live with uncertainty.
5. A willingness to accept that the current basis for your practice may be false.
6. Acceptance that given the same medical facts, the appropriate decision may vary, depending on how the patient values different outcomes.
7. Willingness to question authority. Experts (even renowned ones) may be wrong.
8. Honesty with oneself about one's own biases.

A couple of good posts from a MD blog that is dedicated to EBM with a slant towards pediatrics and neonatology. has a few good jokes as well!

Larry

Advice as Good as Manual Therapy?

This post is a follow-on to one of Larry's previous posts titled:

Advice could be as good as physical treatment for back pain

Larry linked to a press release referring to a LBP trial published by Hay and colleagues in the June 11 issue of The Lancet. The groups were essentially manual therapy versus information and advice, with no differences at 3 or 12 months. A copy of the trial is attached.  Although the trial was well done from an internal validity perspective, Paul Shekelle and Tony Delitto point out several limitations of this study in their commentary published in the same issue (also attached). The limitations are primarily related to the study's incoproration of a one size fits all approach, which has been repeatedly shown to be ineffective. I would encourage you to read their commentary on the paper, as it well defines the issues and why the results of this trial should not be at all surprising.

John

Download hay_lancet_2005.pdf

Download shekelle_and_delitto_lancet_2005.pdf

Screening for VBI: A Hopeless Cause?

Most practitioners recognize the difficulties inherent in the process of screening for VBI in patients with neck pain. However, in the event you have bought "hook-line and sinker" into the concept, here are a couple of papers that may stimulate your thinking in this area.

John

Download thiel_man_ther_2005.pdf

Download childs_jospt_2005.pdf

LBP Classification in Primary Care

Attached is an interesting study just published in Spine characterizing the fact that although primary care practitioners appreciate the potential for subgroups of patients with LBP, the classification methods remain largely based on pathoanatomic models, which have been shown to be incapable of guiding decision-making (and in some cases may be downright harmful). The results of this study is not surprising, but it does remind us there is much work ahead to improve the care of patients with LBP in primary care.

John

Download kent_spine_2005.pdf

Advice could be as good as physical treatment for back pain --- HealthandAge

Link: Advice could be as good as physical treatment for back pain --- HealthandAge.

Advice could be as good as physical treatment for back pain

Let's get the specifics of this study that evidently was put in the June 11th Lancet. Apparently the two groups were pain management group where they only got advice from a PT and a manipulation group (no mention in this article who did the manip). Anybody familiar with this study done at Keele Univ in the UK?

Larry

PTs and MSK Knowledge

I have attached a study carried out by John et al from BMC Musculoskeletal Disorders. BMC Musculoskeletal Disorders releases articles online as soon as they are accepted so the article has not been formatted and is still in word (http://www.biomedcentral.com/bmcmusculoskeletdisord/). I expect the formatted version will be out soon.

This is the piece investigating the knowledge levels of physical therapists and students in managing musculoskeletal conditions. All participating therapists and students completed a standardized examination, which had previously been used to assess competency among physicians. When comparing the scores on the examination from the current study to those previously obtained Orthopaedists scored the highest followed by PTs with specialist certification, PTs without, PT students, then the remainder of the physicians (with various specialties). PTs with board certification scored significantly higher than those without.

I am interested to hear thoughts from others on this.

Josh

Download childs_bmc_musc_dis_2005.pdf

CPR for Predicting Return to Work in LBP Patients

Dionne and colleagues (CMAJ, 2005) recently published a clinical prediction rule (CPR) which was designed to determine what baseline variables in individuals with low back pain will predict a “return to work in good health” at 2 years.  This type of information if robust enough to substantially change our post test probabilities would be very helpful to us.  The best predictive model included 7 baseline variables (patient’s recovery expectations, radiating pain, previous back surgery, pain intensity, frequent change of position because of back pain, irritability and bad temper, and difficulty sleeping).  The model was somewhat helpful for identifying individuals that will go on to problems (i.e. specificity or +LR) it was more helpful in identifying those folks that will not have problems.  In other words what group of subjects is at a low risk for an adverse outcome? 

In my opinion the greatest value of the paper is Figure 3 which is a clinical algorithm to predict the likely outcome of an individual patient at 2 years of return to work in good health.   Practically speaking if a patient doesn’t believe he will be back to work in 3 months and has leg pain then you only have a 25% chance for total success in this patient and nearly 50% (46%) chance that they will not be working at 2 years.  We better be very aggressive in our rehabilitation including a comprehensive program to address the probably fear avoidance beliefs in this patient.

Tim

Download CPR_LBP_RTW_CMAJ_2005.pdf