evidence based practice

[neurospast]

Evidence based practice seems to be the fashion nowadays. I want to play here the advocate of the devil and I am hoping to do a good job.
I will start with an example. Physiotherapy in general in low back pain or more specific manual therapy. In the UK the latest research on chiropractice and osteopathy showed no significant effect of the use of spinal manipulation. A simular research has been done in the Netherlands some 10 years ago with the same result (and here the knock on effect was that physiotherapy was down graded in healthcare provision less treatments payed for by insurances. In Norway a research came to the same conclusion.
How can we talk about evidence based practice if there is no support from research? I have only taken one example but as far as I know hardly anything is research well.

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[Physiobase]

Below is an interesting study that is a double blind RCT and has been peproduced with the same results.

What the full article shows is that in the management of low back pain the manipulation and physiotherapy (non-manip) are better then placebo and gp treatment. Furthermore more that placebo is in fact better than GP treatment.

Most studies continue to fail to document and or test perhaps what is the differential we are looking for. Is it quality of life, stress, pain? Who knows. What I agree with is that we are totally crap at studying what we need to to support our profession. I can only blame the under graduate research tutors and supervisors for this as the under grads look to their guidance both in under grad programs, masterd and PHD's. It really bugs the ---- out of me and many others!

Koes BW, Bouter LM, van Mameren H, Essers AH, Verstegen GM, Hofhuizen DM, Houben JP, Knipschild PG
Title: Randomised clinical trial of manipulative therapy and physiotherapy for persistent back and neck complaints: results of one year follow up
Source: BMJ 1992 Mar 7;304(6827):601-605

CONCLUSIONS: Manipulative therapy and physiotherapy are better than general practitioner and placebo treatment.

[neurospast]

Thank you for your reply, physiobase but this is actualy an example of where things seem to go wrong: There is no conclusion overall when we look at research. Within research when human being are concerned nonconclusive evidence becomes normal. 1 research tells this and another tells that. One must have at least a PhD to be familiar enough with how a research is performed, methodology name it. Still no conclusive evidence about research results and what they extualy imply and this has been since I did my studies, mid '80ties. Now since there has been this hype about evidence based practice as being the way foreward don't you agree that before encouraging such a step it might be a good idea why there are so many controversies in research. Maybe the problem lies that a human being is not to be look at as a constant factor but a far to complex group of variables. If I am right then to my opinion the whole idea of evidence based practice becomes extremely controversial. And I have the impression that neither you are that impressed. Do we have to reconsider how research within physiotherapy is done? I would definetely say so! And leave the higher ground of evidence based until we have something to base it on!
cheers.

[Physiobase]

Thanks for the reply. This is why I posted the above. I actually have a background in pure mathematics and physics at university level before becoming a physiotherapist. And in terms of practical statistical analysis that's the place to understand it. A PHD has no more merit than a school leaving certificate and most researchers employ the services of a mathematician to work out the appropriate stats and power (sometimes) of their research. A few look at it before data collection (perhaps biasing methodology). A few look at it after data collection, again making a statistical analysis fit their needs.

Researches need to under stand the statistical relevence and power of a statistical models results before they even plan their study. This is the first thing to change. Don't do a study to try to make an analysis of when the study doesn't fit. Otherwise the conclusions will be weak at best. It is interesting that when one looks at ratings on the PEDro database that very often they fall below 5/10.

I am a fan of the single case design. Humans are individual. Single case is robust and very powerful. 100 single case designs that show physiotherapy as effective in some way as opposed to not would indeed be a more appropriate look at how we make a difference to the individual. Grouping this into double blind RCT's simply does not work and is a complete waste of time and money.