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”