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Toni Talks about PT Today

Too Much Evidence

Published September 14, 2010 10:29 AM by Toni Patt

I finally got a chance to review the lectures from PT 2010, the APTA's annual conference. The one given by Carol Jo Tichenor particularly caught my interest. Her topic was "Clinical Experience, Patient Values Minimized by Evidence-based Movement" seemed to fly directly into the face of everything the APTA was pushing. In summary, she feels there is an imbalance in the evidence-based movement, resulting in heavy reliance on evidence while sweeping aside the value of clinical experience.

Hers in an interesting take on the subject. I don't disagree. Every course I've taken has required me to produce evidence to support my interventions. I could use clinical experience to decide which intervention but not to support my decision. My experience with the treatment could not be cited. Unless I had a study supporting my decision, the intervention was acceptable.

There are two schools of thought. One stresses the evidence over everything else. The other ignores the evidence and relies on what has worked in the past. Ideally we want a patient-focused happy medium. Somewhere along the line, clinical experience came to be looked down on because it is intangible and not always reproducible. Skill level has an effect on this. Someone who is skilled in a technique is going to have better outcomes than someone just learning it.

Physical therapy needs to stop trying to play catch-up with medicine. Medical interventions are pretty cut and dry. Either something works or it doesn't. That isn't true for physical therapy. We have a vast gray area between working and not working. If a patient fails to improve, the physician blames the patient or disease process. If a patient receiving PT doesn't improve, the treatment is at fault.

It's time to accept not everything we do can be adequately researched. There may never be evidence to support everything. NDT is a good example. There is very little research supporting the use of NDT. There is a lot of clinical experience that shows it to be an effective treatment. Does that mean I should never use NDT?

Part of clinical experience is knowing when a treatment is appropriate. Not all treatments are appropriate for all patients. Maybe the problem isn't lack of evidence but poor patient selection. The best treatment in the world will be ineffective if the wrong technique is selected. Therein lies the importance of clinical experience.

I'm glad Ms. Tichenor brought the subject up. It needs to be said. I wish I could have seen the response in the room when she spoke. She was practically supporting heresy. I hope her message is heard so we can bring some balance back to the evidence/clinical experience relationship.


Toni, For a survivor this article is extremely depressing

Theoretical basis of stroke rehab

I know its old but my experience 4 years ago pretty much confirmed the lack of knowledge.


dean r, living - survivor, world November 4, 2010 4:13 PM
minneapolis MN

I like these comments.  I think therapists have been guilty in the past of get on "band wagons" of the latest technique because there is a course coming up and the reviews and testimonies sound good.   We are not negligent or gullible, but we want the best for our clients and we want to provide services that work.  There have been techniques or 'therapies' that prove to be the 'snake oil' of our day.  There are others that we put into our arsenol of techniques that available to us.  Even medicine is a balance between art and science.  We know that antiseizure medications would assist with seizures but there are many medications just as there are many types of seizures and there is a lot of play in what med or combination of meds will work with one individual's seizures.  We need to use the techniques we know or even discover that work with each client.   There are some issues that PT's see that are more concrete and easy to have evidenced based practice but some issues are nebulous and as different for each client as there are clients with the issue...this is where art meets science and we need to use clinical judgement and trial and error and experience over time.  

Sometimes the outcome is not that the client 'got better' but that the client or the client's family have a better understanding, have developed strategies, are better able to cope, have become better advocates or even have determined what exactly is important to them.  

Good thought provoking blog.  Thanks

Sharon, Pediatrics - Physiotherapist, Infant Development Program September 22, 2010 3:20 PM

Toni, I'm a survivor. I'll give you my take on NDT. My OT was trained in it and if you look at what I acheived with it you would say that it worked. I however think that any clinical experience with it hasn't split out the spontaneous recovery of the penumbra from what can be acheived with the therapy. Now that I have done lots more reading I prefer the Brunnstrom theory vs Bobath. The reason behind that is that NDT requires a therapist standing next to you telling you NO all the time. Brunnstrom allows you to use any movement possible. As a patient it is much more satisfying to be congratulated on some movement rather than constantly being told that what I am doing is wrong. And since I am now on the do-it-yourself model I am not going to be telling myself, No you are using muscles you are not supposed to. If it doesn't look good I will change it later whenever I neuroplastically get the dead brain functions moved.  Anyway I'm just a stroke-addled  survivor, no need to listen to anything I have to say.


dean r, NA - NA, NA September 22, 2010 11:26 AM
minneapolis MN

Toni, I agree to a degree with your post. Evidence does not have to mean that a certain concrete value is attained consistently. For example, look at balance training and fall prevention, of which I'm doing a study on here in the UK. One can approach balance training from a million different angles. What matters is do people fall again after treatment or not? This is one area where the evidence states that the intervention must be a multidiscipline and multifactorial approach. It doesn't matter whether I use a swiss ball, resistance training, a balance board or all of the above, simply does the patient improve after the intervention?

So yes, you are right, our interventions are often too interrelated to point to just one and say "aha!" that is the one that works and only that one. However, we can measure reported pain, patient satisfaction, reported function, observed function, reported ease of movement, and more that will serve as evidence.

Good topic, thanks for posting.

Dean Metz September 14, 2010 10:46 AM

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