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Evidence
in Motion | 13000 Equity Place, Suite 105 | Louisville | KY |
40223 |
MyPhysicalTherapySpace.com - A part of the 1T - the "One Thing" you need for PT practice.
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Evidence
in Motion | 13000 Equity Place, Suite 105 | Louisville | KY |
40223 |
The following advertisement in the latest issue of JMMT caught my attention. Is it possible to have evidence-based rehabilitation when the surgey itself is more analagous to medical prostitution than a medical procedure. A picture is worth a thousand words.
I have nothing against any of the authors and have not flipped through a single page of the text. However, the reference lists in the text must be mostly empty because the following Pubmed search turned up a whopping 0 articles of any kind, even a single case report. See below for the search string and another picture worth a thousand words.
(artificial disc back rehabilitation) AND ((clinical[Title/Abstract] AND trial[Title/Abstract]) OR clinical trials[MeSH Terms] OR clinical trial[Publication Type] OR random*[Title/Abstract] OR random allocation[MeSH Terms] OR therapeutic use[MeSH Subheading])
Perhaps a certified physical therapist will come up with a DIY video on best practice artificial disc rehabilitation.
If you sense any cynicism about my perceptions of the state of our health care system, you could not be more right. We should be marching in the streets over it, but consumers have been duped into a false reality by the cunning marketing of surgeons, device manufacturers, and a culture of quick fixes for back pain as if the human spine is an automobile that can be mechanically diagnosed in the first place.
It's a sad time when patients are viewed as revenue streams and vulnerable to such gross exploitation. I don't blame anyone necessarily for writing a text to help consumers unfortunate to have this procedure done on them to accecss quality rehabilitation so long as the first thing we say to them is "I'm sorry". However, does publishing books like this indirectly attest to the legitimacy of the procedure itself? Will be interested to hear your thoughts.
John
How long will it take us to figure out that the problem of 21st century health care is largely overutilization (except for the poor, who have no coverage, and this is another issue) and poor quality? At least for musculoskeletal conditions, which account for huge and rising costs among payers, unnecessary imaging and pharma are the #1 and #2 contributors to these costs. Hmmm....if you see a physical therapist first, we won't order images nor prescribe you drugs, bypassing the huge cost centers of primary care and speciality clinics like orthopaedics and neurology. If we happen to provide high quality care, great...but frankly patients and the health care system are still better off even if we provide average care. If Jack Wennberg is right, common sense won't prevail anytime soon. This would be a great read over your Christmas break. I hope he is wrong. Push the health care boulder further uphill next year by telling everyone you know to seek care from a physical therapist first the next time they experience an epsiode of low back pain. We just might find the boulder nudged a bit further towards Vision 2020, which is fortunately perfectly aligned with the best interests of the US health care system.
John
Hard Facts, Dangerous Half-Truths, and Total Nonsense: Profiting From Evidence-Based Management
This book written by Stanford's Jeffrey Pfeffer and Robert Sutton take the position that management can follow medicine's lead and rely on evidence, not on half truths (now if we can only get the majority of medicine following this trend!). This book is one of the first times that I can recall where medicine has been the example and business implementing a medical practice. It is an outstanding read and for a very good synopsis of the book, please download this article which appeared in the Stanford Social Innovation Review.
Download 2006SP_feature_Pfeffer_Sutton.pdf
Larry
One of Larry’s top two favorite reads in 2005 was “The
One Thing You Need to Know” by Marcus
Buckingham. I just finished reading
it and found it to be one of mine as well. Whether you are interested in leadership, management, or merely
sustaining individual success, you will find this book invaluable (as well as
the “one thing” in each of these areas, plus much more).
One example given is how Prilosec, a drug for treating acid reflux disease, became the highest selling drug in the world (4 billion a year) from a miserable start in the cellar (only ~200K per year). How did the bright young executive who was given the task of resuscitating the sale of this drug (that was otherwise about to be jettisoned) do it (and how does it relate to physical therapy)?
One of Larry’s contrarian truths of physical therapy is that
the last visit is the most important, not the first. It seems many PTs view it just the opposite
as is evidence by conducting what usually amounts to a data collection safari
on the initial visit. Hey, what are we
looking for anyway?!
Cook County Hospital, 1996: Chicago's principal public hospital is in crisis, with a major contributing problem of indigent patients presenting to the ED with chest pain. The problem is that many of these people aren’t having a cardiac related issue at all (only 10% presenting actually do) yet all were being admitted the CCU for observation at the expense of $2000.00 a day. There was no rational, standardized way of making the decision of who goes to the CCU vs the observational unit. Enter Lee Goldman who collected data and developed what amounts to a clinical prediction rule (CPR) to determine which patients had urgent (relevant) risk factors predictive of major cardiac complications (and therefore needed to be admitted). Based on the ECG and 3 simple findings (unstable angina, fluid in lungs, and SBP <100mmHg) there was a whopping 70% improvement in identifying these patients (95% probability). Was this readily received? No way, after all how could a guide consisting of a few key indicators perform better than a trained physician?
Continue reading "Physical Therapy in Thin Slices…..When Less is More" »
For those of who identify with evidence-based practice, you should not be a big fan of textbooks, instead preferring to stay up-to-date by reading clinically relevant research published in the peer-reviewed literature. Sackett in fact advised in the "little blue book" (or "red book", I can't recall which one) that we burn most of our textbooks since most of them are no longer current by the time they reach our bookshelf and rarely are based on the available evidence in the first place.
A rare exception to the rule has just been published - Josh Cleland's textbook Orthopaedic Clinical Examination: An Evidence Based Approach for Physical Therapists. This text will quickly outpace its competition (no need to mention names) because of the user-friendly evidence tables that are replete with useful diagnostic accuracy statistics (sensitivity, specificity, and postive and negative likelihood ratios) and precise operational definitions of test procedures. More than just a laundry list of every test known to mankind, you can begin to hone your exam to include only the most powerful clinical examination procedures. Josh is a good friend and colleague of ours, so feel free to take my recommendation with a grain of salt. Check it out yourself at http://store.netterart.com/1929007876.html. Unlike almost all other textbooks you may own, I assure you this is one textbook that will regularly come off your shelf.
John
