Wish list for 2016- My positive blog

what I think will take us take the next step:

1. Move from movement specialist to rehab of whole person specialist
2. Move from reductionism to complex systems paradigm
3. Move from calling “clients” and call them as “patients”- you are running a health care centre not a grocery store
4. Move from biological model to complex models in pain and neuro-rehabilitation
5. Move from named course to science based course- call our course as cerebral palsy rehabilitation or back pain management course (the experts should grow some balls)
6. Course on how to convey difficult news to patients
7. Move from osteopathy and other s!@# to physiotherapy (there is a huge science we have no clue- why go behind grocer techniques)
8. Move from distant education to education (the colleges should grow balls)
9. Move from cult organization to patient interest groups
10. Move from publishing in throw away journals to indexed journals

What is in store for physiotherapist in 2016?

What is in store for physiotherapist in 2016?

1.       Jokers will teach NDT, SI, carnio-sacral therapy and gullible PTs will still do it

2.       The IAP and other millions of associations will think they are still relevant

3.       PTs will think these associations can change their lives and call for “unity”

4.       Bunch of dedicated PT s will get disillusioned and will go into their shell

5.       We will still teach the same nonsense they taught me in 1990 and think that is good science (our new syllabus proposed is a great example)

6.       PTs will share more pseudoscience than real information in social media

7.       Collages will “make” the students attend workshops and conference

8.       Clinical therapist will still say- “you can’t exercise with pain”

9.       More self proclaimed experts (jokers) will –teach pseudoscience and ruin as more (examples- osteopathy, chiropractice and dry needle)  

10.   We will still think evidence is for losers and uneducated slobs not for intelligent people like us (and practice the same thing)

Well in 2 words “no s!@#
                

Happy new year folks

Speak up against pseudoscience series - Part I

These are course we think intelligent therapist should shun, So we are starting with the current fad- dry needling

Dry needling- well because it is reinventing the wheel. A group of intelligent people thought- how can we sell our crap? We they were lazy and so they just rehashed some already available assumption with poor science- ie- trigger point and mashed it acupuncture. In acupuncture they have this idea called- ashi point, if I can remember correctly, which are tender points or as they renamed it trigger points with some modifications.
In the last decade they have done thousands studies on acupuncture and it has been found it works only in china when done on Chinese people. So these intelligent people took the lessons from a marketing guru and did what any good execute will do- rebrand it. So as a first step like Airtel called there 3g as 4g they called acupuncture which has lost some credibility among proper medical professionals- they called it dry needling. ( for PT who want to learn wet needling you need to contact Gowdhama Kumaran )

Major problems in this area-

·         No research evidence- that is natural. I know people who teach this will say it is evidence base- don’t worry they have not know clue what is evidence is like most of our us- making it easy to fool us.

·         no physiological sense-  Trigger point is not science as people are made to believe (you can do your own research to learn about it, but start with https://www.ncbi.nlm.nih.gov/pubmed/1404132 done by the people who wrote this )

·         also remember the map they show for trigger point- pulled out of there ass rather than from any study

·         latent trigger point- well, you want to believe this kind of shit no amount of evidence to the contrary is going to shake your faith

·         Remember we have good evidence for multifactoral pain management in chronic low back pain- hence you have to prove it is good than that rather than doing nothing.

Next time i hear someone says i am a expert in this crap i am going to give them an award for being the best therapist in the whole word with my own money

II anniversary of our book: Stroke rehabilitation: an activity based approach

It is 2 years since I and Vasanthan (with great deal of contribution from V. Prakash) released our book stroke rehabilitation: an activity based approach. I still consider it to be my best achievement in terms of scholarly work, even though when I read it, I find the language to be pedestrian.
So what is the book about? Well it is evidence based stroke rehabilitation with non-linearity ideas implemented within the task oriented paradigm.

The ICF model of functioning tells us that function of humans is in 3 levels body level, at the activity and participation level.  Importance to context was given its due diligence and the made clear the multifactoral nature of the influencing factors. Influencing factors were shown in a complex manner influencing each other rather than in a straight line.

Above picture shows- model of influencing factors of activity and participation in stroke. © Stroke Rehabilitation: A Functional Activity Based Approach, K. Hariohm

One of the assumptions I made when I read this was these influencing factors will influence each other in a complex non-linear manner. This was the time we were learning dynamic theory and I interpreted this model as non-linear model. (Well as Vasanthan always accused me – I always interpreted science as I like it or according to my bias rather than looking at it objectively.).
At the same time motor control ideas and motor behavior ideas were also pointing towards a dynamic perspective.

The Venn diagram shows where we have derived our ideas from for our book-as principle of treatment.

Our model within the task oriented paradigm shifted (as you can imagine- we have to be within task oriented paradigm as that is what is evidence pointing towards). We started to look at the system as non-linear system with inseparable subsystems. Even though it looks like the system is made up of many subsystems with unique function, my contention was it behaved as one unit and not separately.  Even though all this mumbo jumbo language is confusing to some it is in reality very simple.
The human system has many sub-systems- the motor, sensory, cognitive, cardio-pulmonary etc., while doing a function all of them act together rather than as individual systems.
What this lead to change in our model of stroke rehabilitation? Well, as you know task oriented treatment is the evidence based proven model, but the problem is definition what task to choose and whether the underlying impairments were to be treated.
Most of the text we read at that time –we started with Carr and Sheppards MRP and moved to other models and around 2005 we were with Anne shumway cooks motor control theory and practice- were not in tune with our changing perception.  The idea we were evolving at that time was- you don’t need to treat the underlying impairment- as I said earlier the subsystems in a non-linear complex system cannot function independent of the whole system. We also thought meaningful ask which are patient centric are the “task” to be selected rather than anything.
So, we started writing our book starting around 1999. Vasanth was dead against writing it as he wanted to find evidence for what I was saying rather than model validation. Well, we went ahead and when I finished one chapter I send it to 3 publishers got reply from 2 and one of them was willing to publish it- The Atlantic publishers (just grateful to those guys). We wrote our book for issues in Indian setting- example in sit to stand- deep knee flexion activities, in and out of an auto etc. Even though writing a book is such a pain it felt good when it was released 10-27-2013.    

If you want to read more about stroke rehabilitation with evidence and the underlying motor control and behavioural ideas-

AMAZON.IN
http://www.amazon.in/Stroke-Rehabilitation-Functional-Activity-Approach/dp/8126918543     

For international shipping

http://www.indianbooks.co.in/bookmart/stroke-rehabilitation-a-functional-activity-based-approach.html?currency=USD                for international shipping
U READ- http://www.uread.com/book/stroke-rehabilitation-k-hariohm-r/9788126918546          

Or mail me: hariohm@hotmal.com         

Should i be afraid- i dont know NDT

Lots of people think NDT or the Bobath approach is the pinnacle of rehabilitation model or the model for Neuro-rehabilitation.

Well is it true?

The simple answer is “no”. But because we have many people who think it is true and some even wear it proudly we will look into the long answer.

So we will start with the fundamental question- what and how was this method developed?

Well it was developed by one of a pioneering therapist in Europe along with her husband around the 1960s.

What was their basic premise?

They took cutting edge science of that time- mostly from Sherrington’s experiments and principles of neuro-physiology and along with it added their own ideas- from observation of cerebral palsy patients.

So what was their basic premise?

They say these children with UMN lesion and the one common denominator they could observe was – “Spasticity”. So they like many others in that time they considered this as the primary impairment and thought this is stopping the patient to move normally. They also tried analyzing the abnormal posture from reflex theoretical idea. (I would ask readers to read this book if you are interested in this kind of stuff- THE NORMAL POSTURAL REFLEX MECHANISM AND ITS DEVIATION IN CHILDREN WITH CEREBRAL PALSY- it was available in British council library  -last time I checked in the late 90s)

So one of the basic premises was “you can do normal movement on abnormal tone” – which was the held it dear even in hers last book- ADULT HEMIPLEGIA: EVALUATION AND TREATMENT in 1990. When I went and listened to this nonsense in 2003 they said the same thing.

What was the basic treatment technique?

Well people are going to go berserk (the followers I mean) for saying this-

Step I- you normalize the tone (ask me how and you need to pay me is still their motto) and next question is how?  Nothing extraordinary just holding in static postures- which they called RIP- reflex inhibiting postures and some other bull shit they called handling.  She gave little credence to “motor learning” like in the era where everything was based on bio-physiological model- she thought if you give appropriate sensory stimuli of normal movement s it will change the system.

What was her major influence in neuro-rehabilitation?

Apart from half educated people making money in her name- her contribution is in the recovery model. Brunstrom thought we have to work with the synergy and then break it later (normal movement) and formulated 6 stages of recovery- Bobath said if we reduce the tone then normal movement can be brought about and changed our thinking about recovery. There is never working with the synergy in Adult hemiplegia according to Bobath.

So what is wrong with it?

Well nothing! It just was not the complete picture of what a patient with UMN lesion is. They did not believe after many experiments- that there is anything called weakness in umn lesion. The operative word here is “believe” not proved or anything. Bobath herself was convinced at the end the aptly named RIP did not work and she said so in her last book.  Well the truth of the matter is she could never be right as she was in a different time. Even Newton was wrong, Arayabatta made a small error in calculation, people are questioning Einsteins quantum mechanics ideas- how can medicine be frozen in time.

Last and the most importantly- most of the studies done all around the world- as this was popular in Europe and Australia – and well they all said do anything else- when compared to bobath or NDT- both are equal. There goes 5000- 4 Lakhs in the toilet for people who studied this.

The newer argument:

The newer argument is very clever and it has all the markings of wonderful marketing by a resourceful pharma.

This is the new definition (anyone who can read the whole thing should get a price)- NDT is a holistic and interdisciplinary clinical practice model informed by current and evolving research that emphasizes individualized therapeutic handling based on movement analysis for habilitation and rehabilitation of individuals with neurological pathophysiology. Using the International Classification of Functioning, Disability and Health (ICF) model, the therapist applies a problem-solving approach to assess activity and participation to identify and prioritize relevant integrities and impairments as a basis for the establishment of achievable outcomes with clients and caregivers. An in-depth understanding of typical and atypical development, and expertise in analysis of postural control, movement, activity, and participation throughout the lifespan, form the basis for examination, evaluation, and intervention. Therapeutic handling, used during evaluation and intervention, consists of a dynamic reciprocal interaction between the client and therapist for activation of optimal sensorimotor processing, task performance, and skill acquisition for achievement of participation in meaningful activities.

(try writing the above paragragh in the exam for the answer what is NDT)

Well what is wrong you moron you ask me. The answer is that is not the definition of NDT that is the principle of rehabilitation not even neuro-rehabilitation. You can’t define your 2 bit nonsense as that of rehabilitation. For example if you ask what is task oriented approach- you simple say- you keep on doing the task as a whole rather than parts –something like that.  You don’t put a- 15 page definition so that no one can do any study in neuro-rehabilitation without being in your scope. If that is what you want then you should call it science not NDT.

Task oriented practice is NDT:

Well, that is physiotherapy not NDT.  The idea was developed by many people especially 2 Aussies- Shepard and carr (incidentally they also learnt Bobath) and researched by the whole world. (There are 2 wonderful studies from India if anyone wants to read). So you can’t call it yours and charge some poor sap- 2 lakh rupees.

We incorporate from all the new findings as NDT is fluid!

Of course, that is what every PT does- especially if you take the good and practice it is called EBM.  If you add evidence with some mumbo jumbo like handling, key points than it is called NDT and charged 2 lakhs. You don’t brand latest science in physics as Indian physics or European or cipla physics and sell it. you cant take latest finding in research and call it NDT- you should call it PT.

We are educating the masses what is wrong (genuinely there are some people who do that).

Well if you are propagating pseudoscience- I think it is a crime and unethical thing to do. Well any one with half a brain will not take medicine which is not good, then why teach things which don’t work.  So you are not educating the masses you are encouraging half educated nitwits from other country to exploit our novice PTs.
Some nitwits also think they have brought some experts from the land of science and they are doing a service to the society by teaching this nonsense for just 50 thousand. Really?   

How are these people surviving even after so many studies, so many criticism- well they find new ways to market old garbage as antique to gullible PTs.  We as a people have fascination with the word international, certified etc and this is exploited. Over this we have syllabus which still has these in the syllabus- if you ask the nitwits who are experts in academics will tell you- these are important traditions. Well physiotherapy student does not come to study history – they come to study science.

So what should an intelligent Therapist do?

Well it is fairly simple and it is free. Don’t worry about any technique. If someone says he/ she is certified NDT therapist- laugh at them for wasting their money.
Read simple task oriented approach literature or just remember if you want swim- dont go to the gym go to the pool- that in a nut shell is latest neuro-rehabilitation principle.

PS- no homer simpson quote- as the definition of NDT is enough for the joke

On cerebral palsy day PT the 10 things we should do:

1. Just come out our cult- whether it is NDT or SI and read science

2. remember there is no abnormal movements

3. well we cant change abnormal movements- but we can make them achieve there goals

4. Educate patients with level IV and V regarding accepting - wheelchair

5. keep you hands of pelvis and trunk and allow the patient to explore options

6. Posture correction -well if this is physiotherapy for children with cp- well just quit peadtrics

7. If you are putting the child in a dark room, binding them etc- well that is child abuse and you should be locked up

8. If you are encouraging kneeling for 15 minute or something- well you are a moron-stop practicing physiotherapy

9. for a child with sitting balance if you are treating the patient in lying or on a swiss ball- well quit or read

10. If you are one the morons who keep on asking me if not NDT what else is there - just read or do nothing- because NDT is as effective as doing nothing.

PS: please for god sake only uneducated people will be impressed if you are trained and certified in NDT

additional reading: 

A systematic review of interventions for children with cerebral palsy: state of the evidence.

http://onlinelibrary.wiley.com/doi/10.1111/dmcn.12246/epdf

Should we teach cult based concepts in universities?

I usually don’t get perturbed by PT syllabus- what is changed and what is not etc. I know from many years of teaching nothing changes in the syllabus – from my observation in the TN MGR University.  As time goes by I understood everything remains the same. A classical example is splitting the exercise therapy syllabus into two into 2 papers but having the same content from that horrible book- Dena Gardeners exercise therapy – keeping PT in the 1980s. And this is still in the syllabus in 2015 but we have 2 papers in exercise therapy.

The other day I saw the new and improved syllabus put forth by the ministry of health. I am not going into the finer details of it as I said earlier nothing is going to change. However, I am going to raise a single issue in the syllabus (proposed) that is inclusion of 2 products as part of the curriculum.

A medical product is usually a drug which can help in treating a disease.  The drugs are developed by a complex process and usually end with someone patenting it and selling it to us. They also have a monopoly for sometime in not allowing others to use the formula.  As time goes by generic variation are done and usually sold in a much cheaper rate. In physiotherapy medical products traditionally was instruments which are extensively used ranging from SWD to the modern lasers. However, along came some PTs who had an ingenious idea of how to treat some neurological and painful conditions. They were pioneers in our field starting from Knott and Voss to Mulligan. They also wanted other PTs to practice their ideas and started teaching it to other leading to newer ideas and discussions.

So, what went wrong? Well PTs with these ideas started forming cults with themselves as leader and adherent followers. Even at this point I am not unhappy even though I think it just ruins science. Some of them started to sort of patenting their have baked ideas and claiming others should not teach them. I am assuming the reasons for it is predominantly fiscal and some amount of thinking others will corrupt their idea- leading to lose of fidelity of the concept. Whatever, their thinking I don’t give a rats a$$. They even send notice to people who teach that- I personally know people who got it for teaching McKenzie treatment. The Mulligan cult is famous for saying in the brochure itself no one can teach the holly shit they have formulated. Well, I still think it is up to them to say it and protect their product. These are not hard science, these are one persons teaching with or without any facts and hence not a problem when all of us don’t know how to do these techniques.

 So pray you ask me, “What is your problem?”  The problem is Mckenzie and Mulligans school of crap is in the draft syllabus prepared by the ministry. How come a product with poor science and which cannot be taught as claimed by product ceos is in the syllabus. OK, even if you say the concept can be taught, the question still remains why? This is like saying you can run the trailer but to see our movie you have to pay us 20000 Rs. As most of you know I hate NDT because they are just lazy, parasites who take the work of others and sell it, but at least they don’t ask other not to teach their useless product. To have in the syllabus – Electrocare IFT rather than IFT is just plain wrong. Likewise, a product with poor science and which cannot be taught by others other than by authorized by the CEOs is just not done in Universities. Already we are selling nonsense like Dry needling to K-tape without any shame to naïve therapist outside the preview of the educational system- but universities should not be helping fat cats sell their crap.
Let universities be where we learn science. 

Word physiotherapy day- How should we call ourselves?

This is a positive blog, which people complain I usually dont write about. Well many of us think we are pain experts, movement science specialist (a term encouraged by Carr and shepard) and so on. However, I think having a restricted definition is not defining us fully.
what should be changed.

What is health?
The WHO defines it as -Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity

There are 2 parts to this definition- the most salient part is it does not talk just about physical, hence my contention we should not call ourselves- movement science specialist. We are more than that we make or we ought to make persons with disease function in the world not just change their pain or movement.

It took me some years to understand my patients with cerebral palsy are worried more about toilet training rather than kneeling.  Not just pain relief, but again ride their motor bike back to their job. There are many more examples which I need not point to our community as we all have made a great deal of change in our patients beyond just movement. Hence we need to think ourselves and refer ourselves as health care professionals with unique skills, which cannot be restricted to movement or pain alone.  I am not sure exactly how that “unique “should be defined- maybe we can all opine? but it should be more global than pain and movement.
The second part of the WHO definition is sort of technical- really complete absence- is it really possible.

love 

Hariohm K

My high horse post

As September 8 is fast approaching let’s take an oath to stop some rubbish which has crept into our practice:

We need to stop giving rubbish advice and health educations like:

1.       Don’t sit on the ground if you have OA knee or walk –really, does it look like sound advice? As Prakash V used to say – if you have OA Hip should we give an advice not to sit on a chair? Not to walk because you have OA? Really!

2.       Don’t bend if you LBP- really? Compounded by half baked advice from ortho- this is the new trend. Then what is the joint for and how are they going to function? read

3.       Don’t terrorize you patient into taking treatment- this one is also for the poorly educated health care professionals of all size and shape. If you don’t do the surgery you will be a cripple and die or the joint will be going to dust if you don’t attend my clinic- stop these type of advice

4.       Remember educating the patient is a vital tool as any other- don’t be afraid of honest education and advice of the patient

In neuro-rehabilitation we need to stop:

5.       If your major part of CP or stroke patients management is passive movement and stretching and rolling the child on a ball or a swing- well read become a physiotherapist

6.       Stop using props like Swiss ball, bolsters  and use real world useful things- they have come to rehabilitated themselves and function in the real world not join the circus

7.       In neuro-rehabilitation remember the patient did not come to you to change his trunk or pelvic alignment- stop thinking like a car mechanic and set goals which are valuable for the patient and work towards achieving it. Don’t believe idiots who teach you those are vital

8.       Well my favorite- don’t say you are a  certified NDT therapist it does make you look like a fool when it has been said time and time again it is not a great treatment. The world is moving on –so read and become an educated Physiotherapist

If you are a teacher

9.       If you are a teacher- just throw the notes away- read and prepare for your class.

10.   Stop gossiping – if the boy is not going around the girl then it may be out of the ordinary, so just shut up

11.   Stop telling them how to dress and talk- rather teach them to think and behave ethically with the patients- who cares if I wear I jean, but it hurts when they ask “ where can I get this-professional ethics you are talking about”

12.   Allow them to express- if you don’t know what it mean please learn

If you are in pain management:

13.   If major part of your management strategy of pain is passive techniques including manual therapy, suluku edupathu or electrotherapy- well read

14.   If you think MET, manual therapy is the latest- well read

15.   If you think you should not teach exercise when the patient has pain –just stop practicing PT you are a embarrassment to the great science- Physiotherapy

I know lots of people are going to think I am being an ass and supercilious- well ….

Love

Hariohm

Follow the evidence not the guru

Beware of the cat if you are mice

Follow the evidence not the guru

What is science? Simply put science is seeking of truth or knowledge based on experiments or research. If knowledge is not based on research and just of personal observation then it becomes a matter of faith. In physiotherapy science “approaches” or technique starts with personal observations, theoretical considerations of that particular time and ingenuity. This is true for all the approaches in neurology starting from Knott & Voss PNF to Carr & Sheppard’s MRP. When these approaches are first written it was derived from cutting edge science of that day and even it was considered revolutionary. For example, when Bobaths wrote their book on adult hemiplegia they departed from Brunstromm’s Ideas of recovery and treatment principles.  (Bobath moved from a 6 stage recovery to 3 stage recovery process in stroke.)

 But, research into various treatment methods and approaches was not carried out before they were published. One of the early examples of it is weakness as impairment in upper motor neuron lesions (UMN) was identified as a problem in the late seventies. In the late 80s and 90s it was being more and more recognized as an important impairment in UMN lesions. However, most of curriculum, our training methods did not consider it to consideration. Even as late as early 2000 course on cerebral palsy was reducing spasticity and considered weakness as non-issue.  Major reason for it may be because we follow “approaches” propagated by “experts” and there followers rather than research or evidence. 

What is evidence? 

Evidence is a piece of information that supports a conclusion and in case of medicine the information should be patient centric and clinically relevant. One of the best ways to do an experiment to find effectiveness of a treatment is randomized control trials.  In the last decade as auditing and evidence based practice became the norm and we started to understand the importance of experiments in physiotherapy science and knowledge acquiring.  Randomized control trials (RCTs) on the efficacy of these approaches increased in the last decade. Even though evidence is part and parcel of science, soft science like medicine has different grades of evidence.  The quality of the evidence is vital for our understanding of medical science. The analogous I usually give to

Levels of evidence - treatment

understand different quality of evidence is the quality of gold. As we know gold comes with different level of purity and depending on that the quality is listed. Gold can be 24, 22, 18 or just 16 carat gold. Similarly, evidence can be different grade depending on the quality of the trials done. When good quality trials are combined together and made into a systematic review (SR) we can assume it to be high quality (something like 24 carat gold). When the trials (RCTs) are done with some bias or flaws and when they are part of the SR it can be considered as moderate evidence (20-22 carat gold!) and poorly done studies leads low or very low grade (12-18 carat gold) evidence.  It is common to see moderate level evidence rather than high quality evidence, that too in stroke rehabilitation at this point of time.

What does evidence say about gait in stroke rehabilitation? 

A Cochrane review in 2014 concluded “Physiotherapists should choose each individual patient's treatment according to the evidence available for that specific treatment, and should not limit their practice to a single 'named' approach” and no one approach is superior to another.  I believe this is our next evolutionary step, to find and apply treatment for each problem rather than following a guru’s approach.  We should be proudly saying I don’t follow an approach or that technique alone but, say I am follower of science and evidence.

These are the following issues we will find if we look into evidence for walking after stroke:

1. Physiotherapy works and it improves gait in persons with stroke - It may look like a simple statement and we may think I already know that but, it is an important finding, because the research (Cochrane reviews and other systematic reviews) says so rather than experts or just clinical intuition alone.
2.   The next question which arises in our mind next is -What physical rehabilitation measures work? - Systematic reviews on gait rehabilitation have noted a repetitive practice of functional or a task. Primary focus of repetitive practice of task-specific training of everyday motor tasks. Repetitive or task specific practice, simply put means doing the activity which you want to improve again and again. So, to improve walking in persons with stroke repeated practice of walking is the best exercise. Remember, exercise done on a couch does not count as repetitive walking task training.  
3.  How long do my patient needs to practice these activities to get better. One systematic (Cochrane review) review identified, probably 30-60 minutes of practice may have beneficial effects on gait in persons with stroke than lesser intensity.  It should be noted 60 minutes of training can consist of training other tasks like standing sit to stand etc.
4.  What does evidence say about people with stroke who can walk independently and want to improve their competence in walking? Evidence suggests (Cochrane review) doing circuit

   

   A simple circuit training stattions

   training, treadmill based gait (Cochrane review) training and repetitive task training (Cochrane review) are the best available methods to do. Circuit training consists of repetitive practice of functional tasks and continual progression of exercises. The participants may complete a series of workstations arranged in a circuit or may complete a series of individualized exercises within a group setting. It has been suggested circuit training can be a good way to improving and maintain walking competence. 
5. Treadmill based gait training can again improve parameters like walking speed in patients who are already able to walk independently, especially in the first 3 months.  It must be stressed it does not matter whether the training is done with or without body weight bearing support and it does not produce great value in chronic patients and people who cannot walk independently.

   

   Why worry and buy a expensive and space eating sytem

6. 

   A obstacle training course

    Community ambulation is the ability of the patients to walk in the community, to participate like walking to the temple, going to the shop, to the bus stop etc, and it is the goal of stroke rehabilitation. Two types of training have been suggested by researchers 1. Simulated walking training like in the community (obstacle training) 2. Walking training outside in the community.  Individual studies rather than systematic reviews suggest we may be able to use task specific training to make persons with stroke community ambulatory.  However, remember more research is needed in this area.

   

   Community walking training

7.  We have very limited research evidence to prove that we can improve the quality of the movements (i.e. altering the gait pattern). One of the ways it has been suggested is to make your patient walk faster. So, what should we clinicians do? Try out different feedback techniques to correct movement pattern including walking faster. Clinicians should be aware physiotherapy may not be an effective tool to change gait patterns and patients should be educated regarding residual gait pattern abnormities.
8. Regarding reducing impairments like contracture and spasticity what does the evidence say? Stretching probably does not reduce contracture or prevents it from developing. Spasticity as a impairment is difficult to manage, however, drugs like Botox does offer reduction in spasticity but not functional improvement. Strengthening exercise may improve muscle power or strength but we are not sure whether resisted exercise helps in improving gait performance. Evidence clearly shows strength training  does have harm effect (i.e. it does not increase spasticity)
9. What are the issues we don’t know? We are not sure whether physical rehabilitation for chronic patients who are unable to walk can be helpful. We don’t know what is the best prevent contractures, best way to improve walking if they have moderate to severe perceptual problems.    

Conclusion: Even though evidence based physiotherapy is showing us the way to plan a rehab protocol in stroke rehabilitation, sadly their findings and implementation of the findings are not as positive as it ought to be. This can be attributed to many factors including, traditional teaching and practice models, difficulty in understanding evidence etc. The next decade in physiotherapy is not going to be about finding the next cutting edge physiotherapy technique, rather it is going to be about applying the best available evidence and producing more evidence.  It is not going to be mastering a technique or approach rather follow evidence, finding what best works for patients with evidence. I am concluding by saying “following the evidence rather than the guru” is the secret of best practice.

Reference and additional reading:

1. Mehrholz J, Pohl M, Elsner B. Treadmill training and body weight support for walking after stroke. Cochrane Database of Systematic Reviews 2014, Issue 1. Art. No.: CD002840. DOI: 10.1002/14651858.CD002840.pub3http://www.cochrane.org/ta/CD002840/pkkvaatttirrku-pirrku-nttntu-celvtai-meempttutt-oottupeaarri-mrrrrum-uttl-ettai-taangki-pyirrci
2. English C, Hillier SL. Circuit class therapy for improving mobility after stroke. Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No.: CD007513. DOI: 10.1002/14651858.CD007513.pub2http://www.cochrane.org/CD007513/STROKE_circuit-class-therapy-for-improving-mobility-after-stroke
3. Barclay RE, Stevenson TJ, Poluha W, Ripat J, Nett C, Srikesavan CS. Interventions for improving community ambulation in individuals with stroke. Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CD010200. DOI: 10.1002/14651858.CD010200.pub2http://www.cochrane.org/ta/CD010200/pkkvaatttiliruntu-pilllaittvrkll-avrkllinnn-ceaant-cmuukttil-nttmaatt-utvum-cikiccai-tlaiyiittukll
4. Pollock A, Baer G, Campbell P, Choo P, Forster A, Morris J, Pomeroy VM, Langhorne P. Physical rehabilitation approaches for the recovery of function and mobility following stroke. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD001920. DOI: 10.1002/14651858.CD001920.pub3http://www.cochrane.org/ta/CD001920/pkkvaatttirrku-pirrku-eerrpttumuttl-ceylpaattucmnilai-mrrrrum-nttai-upaataiklliliruntu-miillvtrrkaannn-uttlcaar-mrruvaalllvu-annukumurraikll
5. Katalinic OM, Harvey LA, Herbert RD, Moseley AM, Lannin NA, Schurr K. Stretch for the treatment and prevention of contractures. Cochrane Database of Systematic Reviews 2010, Issue 9. Art. No.: CD007455. DOI: 10.1002/14651858.CD007455.pub2http://www.cochrane.org/ta/CD007455/tcai-ottungkllinnncontracture-cikiccai-mrrrrum-tttupptrrku-tcai-illkkll-cikiccaistretching
6. Prabhu RKR, Swaminathan N, Harvey LA. Passive movements for the treatment and prevention of contractures. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD009331. DOI: 10.1002/14651858.CD009331.pub2http://www.cochrane.org/ta/CD009331/tcai-ottungkll-cikiccai-mrrrrum-tttupptrrku-purrvicai-muuttttu-acaivukll

Surgery or Physiotherapy

At last I got whatsapp in my phone.  As I have dreaded it is just a headache- people just dump all sorts of things and it just comes and sits on my phone.  One of the junk which reached my phone is a news report on a scientific study which compared surgery vs PT.

It is good news that PT is as effective as surgery and when we look in the health economics of it, this is wonderful news. I am not going into the methodological issues of the research or most of the sharing was the news item rather than the original study (not even a supplement attachment), but rather a different issue all together.

For many years the evidence is saying- manual therapy is as good as an exercise program in most of the conditions, NDT is not superior to anything you do for cerebral palsy or it is just useless in many conditions “the international expert” claims it to be.  But when we point this out and tell our fellow PTs – sulukuedupathu- (the original terminology for myofacial release) or 5- 20 thousand Rs manual therapy course or the original pirates- NDT which cost you anywhere around 3- 5lakhs is as good as a simple good exercise program which you can learn for free, PTs just go berserk.

Sadly, we are doomed to be a profession with pseudoscience, cheating, following any idiot as expert (and learning and being certified in his crap) is not going to go as long as we have suckers who will join these courses for so much of money.
where is whatsapp sharing about these info…. 

“It takes two to lie: one to lie and one to listen”

Quo vadis Indian Therapist?

Quo vadis Indian Therapist?

Around June 2013, V Prakash posed a question to me when we were having our daily end of the day conversation- the question was “how many studies have we (Indian therapist) done till today”. He also added that we should find it and post it FB so that we will all know where we are standing.  We both agreed it was an idea worth pursuing.

When we started searching, we landed with a huge number of hits in the Medline including dental, yoga studies and what not. We thought we are making a mistake in search terms.  We wrote to Medline help desk and they also said it is difficult to search specifically for Indian therapists and studies done by them.  From the 934 hits we had from the search string we gave (please refer to the article for details) hand searched each article for PT author- hours and hours of staring and searching  for authors if they were therapist or someone else. Well at this point we thought well if we are going to pursue this we need to do this as a bibliometric study rather than as a small blog on FB.
We were at this point joined by J Sarvankumar and we started to code around 165 articles using the methodology of a previous study . This was just tedious work as we did not have web of science access which would have made the task simpler and we would have run the data from it through bibliometric software. Well we didn’t have the resource. (We will publish the whole study in a few months as it is under peer review in a journal.)
When we were looking in to the coded data we found there was a steady increase in the RCTs. We wanted to know what are the quantity and quality of them (RCTs) alone. We know RCTs are very difficult to do and publishing them is a herculean task. We wanted to highlight the production of our therapists, at the same time wanted to know the quality of those trials.

More data analysis, finding full text and this time we had to read the whole thing to code it and analyze it.  Luckily many of the journals did give us free access and some we would not find it. 2 instances I remember are one from Recoup (Dr. Sharan and his team) and one from my friend Harpreet Singh readily sent us the full text when we would not find it by ourselves, my sincere thanks to them both. We also could not find some full text and after repeatedly mailing the authors I would not get it (hence you will see some missing data in the study).

What did we find? Just the key findings

1.       We are getting better at producing RCTs- especially - Manipal university (don’t know what the hell universities with huge resource are doing or the all the government institutions).

2.       I have a great deal of respect for people who can do RCT- we are trying do for quite some time hence I know the pain and difficulty, but some of the studies could have been done with better methodology and  better reporting. In one study it was written as double blinded but we just would not find what they blinded by reading the article.

3.       We did not report it in the publication- but the explanation of the intervention was very poor.  For example reporting that “…we did tailor made exercise for improving symmetry…” does not help us to replicate it in the clinical setting. (Click here for reference). At the same time, one of the earliest trials done by a Indian therapist was reported very well in terms of explanation of the interventions.  (the trials were coded for explanation of  intervention according to Hoffmann et published criteria)

4.       I personally don’t like studies on “healthy people”- the sports studies. In a country as large and with so much of burden of illness why waste our intelligence, time and money and making people run faster- when millions are suffering from LBP, stroke and other cardiac conditions. I would urge Therapist to do more RCTs based on the burden of NCDs (Non Communicable Diseases) of India. The wonderful example I can point to, are the studies done on people with diabetes, a condition with huge burden in India- which was studied in one RCT (click here for the study)

5.       I am going to get into trouble for saying this- anyhow- I found one study done on a group of basket ball players and published as 2 trials – just the outcome measure is different. I think this is just useless waste of time and looks like borderline ….. well I don’t want to say it. Please look into both the studies and you decide- (click here for study 1 and click here for study 2).  

6.       We should be proud and bow our head to all the people who have contributed to the production of RCT- as most of them have done without no funding, no mentoring and against all odd. 

7.       I know lots of these journals do not insist on CONSORT guidelines on how to report a RCT; I just hope our hard working researchers anyway follow it while writing. As a primer we can insist our PG students to follow it as a practice while doing there dissertation.

8.       We had so much difficulty in publishing this because- who the hell cares about Indian therapist research production. After finishing the study it took us many months to get a journal with relevant scope and we ended with Perspect Clin Res. It is time we develop a proper high quality peer reviewed journal.

Additional reading:

1.        Avoidable waste in the production and reporting of research evidence

2.       Read our article @ Quantity and quality of randomized controlled trials published by Indian physiotherapists

Love

K. Hariohm