MyPhysicalTherapySpace.com - A part of the 1T - the "One Thing" you need for PT practice.

The World is Flat

I recently attended the strategic planning conference for the Division of Education of APTA. Although I was dismayed that so few educators at the conference knew anything about evidenceinmotion.com, it was a good opportunity to share the concept. We need to get the word out!

We were given several readings to push us to think "visionarily" about the future and education in particular. One of the most fascinating readings was Thomas Friedman's The World is Flat. Friedman chronicles the last 15 years and forces the reader to recognize the connectedness (i.e. flatness) that is our present world. It has challenged me to recognize how much our world has changed in the last 15 years and to think about the forces that have produced and are continuing to produce this change. Technology is the catalyst, empowering single individuals and groups of individuals to be innovative and entrepreneurial through the utter connectedness that has created our flat world.

Friedman talks a lot about today's business practices with regards to seamless, global communication and collaboration - and it makes me wonder what will be the great catalyst that will force health care and education into the 21st century? Could EBP be one of the catalysts - through the empowerment of single individuals to seek out "truth" and best practices - and then to apply them, one patient at a time? Will this individualism be the derailing of the special interests groups such as pharmaceutical companies and physician owned hospitals? One can only hope.

The book is a good read for anyone who wants to be challenged to hope for our future....

Dale Avers, DPT, PhD

Why Classification Matters

We have repeatedly emphasized why classification matters in a variety of posts on our blog; however, here is a good post from Doug Kelsey reiterating its importance. Enjoy the read. It's good to see blogs relevant to physical therapy practice are catching on.

John

Printed Materials & Marketing

In response to Jason’s inquiry, considerable effort continues to be put into establishing the effectiveness of various physical therapy interventions. Interestingly enough, one area that has been relatively understudied given the fact that it is virtually ubiquitous throughout health care is the influence that printed educational material (such as guidelines, practice parameters, etc.) has on influencing practice behaviors and most importantly, patient outcomes as a result of those behaviors. This Cochrane review by Freemantle and colleagues does just that. The jury is still out on this one, but there does appear to be some small impact and some approaches are better than others. Cochrane currently lists update protocol in progress for this older review.

 

At Evidence In Motion we have and continue to develop printed educational materials designed to educate and thereby influence the referring and practice behaviors of physicians and other providers as well as those of physical therapists. One of these items is an evidence based monthly newsletter (example attached), others include more detailed evidence summaries, abbreviated summaries, press releases, etc. Does anybody else care to share what they are doing with Jason and the rest of us?

 

Thanks,

 

Rob, Larry, and John

 

Download EducationalPrintedMaterialsFreemantleOldCochrane.pdf

Download musculoskeletal_monthly205.pdf

More of the Same from the ACA

The American Chiropractic Association (ACA) gets an A+ for effort, however they fail quite miserably when it comes to accuracy. Attached is another letter from the ACA full of misinformation regarding which states preclude physical therapists from performing manipulation - this time to Health magazine concerning a a recent feature on the spinal manipulation paper recently published in Annals of Internal Medicine. Similar to their previous letter to More magazine (same song, different verse), their list of states whose practice acts preclude physical therapists from performing spinal manipulation is entirely wrong. Interestingly, he even left off one state that does actually preclude physical therapists from performing manipulation - West Virginia. I have contacted Don Krippendorf, President of the ACA, on multiple occasions to no avail regarding the inaccuracy. Given his lack of response, I have attached the letter I originally sent to him regarding the letter to More magazine. You never know - perhaps some of the ACA staff read the blog more than he responds to his email. The same letter could be sent regarding the most recent letter, but the ACA doesn't seem to be interested in correcting factual errors. You be the judge. Let me know if you have any questions.

John

Download 07l2manipulation_prediction_rule_aca_letter_jun_05.pdf

Download 07l3manipulation_prediction_rule_response_to_aca_jun_05.doc

Download 07mmanipulation_prediction_rule_aca_letter_jul_05.pdf

Methods and Procedures

I have encountered a dilemma. A rather well-done RCT with blinding and a placebo control group (a level 1b study per the Oxford Centre for EBP) finds that post-op TENS was not effective in decreasing the amount of analgesic in post-op pain following TKR (Breit R & Van der Wall, H; 2004). However, upon reading the procedures, the authors did not report the setting used on the TENS unit. Instead, they set it at the maximum output level and told the patients they could change it as necessary.

In a meta-analysis of TENS and post-op pain (Bjordal, Johnson, Ljunggreen; 2002), the authors pooled subjects from only RCTs evaluating TENS effectiveness in reducing the amount of analgesic and found TENS reduced the amount by ~25% (MWD) more than placebo. Further, when a subgroup of "optimal setting TENS" was analyzed, the authors found a 35% (MWD) reduction in analgesic more than placebo. Only 4% difference favoring the analgesic was found when pooling 9 trials without explicit information about sufficient current intensity and adequate frequency.

So, my question is - where do procedures figure into the level of evidence? This question also comes up when evaluating the effects of exercise on function in older adults. Many older studies only used low intensity exercise as the intervention and concluded that exercise was not effective in improving function in older adults. However, when one uses moderate to high intensity exercise (depending on the initial threshold of the subject), results are strongly in favor of functional improvement. And yet - both types of studies are well designed.

Anyone care to comment on how a clinician is to weigh a well designed study (and thus a high level of evidence) that uses ineffectual procedures and still keep the EBP process to Sackett's goal of "20 minutes"? Where do procedures fit into the validity of a study?

CME: "Shadows & Dust"

CME: “Shadows & Dust” 

In this line from the movie “Gladiator” Proximo the gladiator trainer tells the General (Maximus) that his perspective and vision of Rome wasn’t consistent with reality, urging him just to accept things the way they were because after all, “we mortals are but mere shadows & dust Maximus, just shadow & dust”.

In keeping with the theme above, is our perspective of CME obscured by shadows & dust? Shadows & dust (as well as smoke and mirrors) certainly seem to obscure our view when it comes to CME. A common thought in EBP is that CME is not effective in changing clinical behaviors. I know myself and many of my colleagues have touted this as being fact. This tenet is based on a 1995 systematic review of the topic published in JAMA by Davis et al. and comes right out of the Sackett EBP text.

Politics and Evidence-based Practice: A Dangerous Combination?

This article is a perfect example of how politics and evidence-based practice don't always mix well. It seems the Prince of Wales has an "evidence inflation" problem on his hands in the UK. The prince is evidently a complementary alternative medicine enthusiast and sought to influence goverment policy by commissioning a government report on the benefits of more broad coverage for these services in the NHS. The "only problem" is that the report isn't exactly accurate, apparently grossly overestimating the potential cost savings. Edzard Ernst, a Professor of Complementary and Alternative Medicine at the University of Exeter, even asked to have his name removed from the final report because he felt the conclusions were so grossly misrepresented. This is another example demonstrating that politics and evidence-based practice can be a dangerous combination.

John

Marketing/News Releases PT Month

Hello everyone...

I am looking for pertient news releases or marketing articles for use in the upcoming PT month (October for those not in the USA). As much as I look forward to writing them myself, I have a feeling that among such august company here there might be some people with some good ones already written that they might feel comfortable posting to the blog.

I am specifically looking for an article or news release on manipulation and the CDR (John C, throw me a bone?) or anything else anyone is writing or has written in the past that in general serves to improve the state of knowledge of the public regarding Physical Therapy and Physical Therapists. Given our chronic marketing problem, I thought it best to solicit from experts first, as we all might benefit from each other's experience and previous work instead of "reinventing the wheel", so to speak. Or I could just be lazy, I'm not sure. Just kidding.

I know the APTA and the AAOMPT are getting better at helping in this area, and their examples are a good start as well.

Thanks for any help or submissions for the good of the group, have a great day.

Jason.

Feedblitz

For those of you who have become accustomed to reading the EIM posts in your email, you will notice that we have switched email engines from bloglet to feedblitz.  There is no need to re-subscribe as your address was imported into this new engine.  We are also adding podcast ability and will be introducing our author in a room and vidoeconferencing ability in the near future. 

Larry

Prognosis- low back and neck pain

The latest issue of Spine had a few interesting articles related to prognostic factors for outcomes in patients with spinal disorders. The first article identified the patient reported level of bothersome to be directly correlated with the level of severity of LBP. The reported level of bothersome can potentially be useful in identifying loss of work time and need to see other health care professionals at a 6-month follow-up.

The second article by Bekkering et al identified that the most robust prognostic factor in patients with LBP referred to PT was duration of symptoms. Conclusion: the longer it is before they are referred to PT the poorer the prognosis.

The 3rd article deals with predictors of outcomes for patients with neck and shoulder symptoms and provides further evidence that psychosocial factors can have a significant impact.

Some interesting reading…

Josh

Download Bothersomeness_LBP.pdf

Download Prognostic_factor_LBP.pdf

Download Predictors_chronic_neck_pain.pdf