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

Time to think of education

Time to think of education

One of the sad news I read today was in The Hindu (click here to read). It talks about why children in rural India die of diarrhoea and pneumonia based on a JAMA article. It has 2 lessons I believe: 1- how poor our training of health workers in India and 2- this is for all the therapist- this is what we mean by burden of illness and priority public health.

One of the reasons I am writing this blog is a selfish reason but with some value to all of us. There are very simple methods to prevent diarrhoea related death. The WHO has given clear guidelines of how to manage these patients but alas the health workers (including physicians) had very little idea on management principles.   The reasons can be laziness of the health workers, poor training, plain stupidity and lack of empathy for poor.

But I believe one of the major reasons forgetting what medical professional’s important tool- education and empowering patients. What it means is the health care workers don’t want to take the time to make the patient understand the disease, simple solution they ought to do rather they just prescribe something and hope it will all go away.  (I see similarity in therapist treatment of pain also but that is for another time). Of course the study also highlighted the over treatment (just like us PTs) and prescribing drugs for people who just were not sick.

The sad part is I don’t see and association of health workers or physicians making a hue and cry- I can remember when someone told on TV the stupidity of screening they all were up with arms, but …well fill.  I am not going to talk about the 2 issue. (This is for all the therapist- this is what we mean by burden of illness and priority public health.)

So what is the selfish reason-well I am going to give some links to how to treat diarrhoea from Cochrane and well it is Tamil. Please read it and also spread the message.

1. 1.       தீவிர வயிற்று போக்கிற்கு (polymer) பலபடி சார்ந்த வாய்வழி அளிக்கப்படும் நீரேற்றல் கரைசல்கள் (ORS)
2. 2.    குழந்தைகளின் கடுமையான வயிற்றுப் போக்கால் ஏற்படும் நீரிழப்புக்கு வாய்வழி குறைக்கப்பட்ட ஊடமைச் செறிவு (osmolarity) வாய்வழி மீள்நீரூட்டம் (rehydration) சிகிச்சை
3. 3.    குழந்தைகளில் பேதி சிகிச்சைக்கு வாய்வழி துத்தநாகம் கூடுதல் உட்கொள்ளல்

The stupidity of assuming we are alternative medicine

The stupidity of assuming we are alternative medicine

I was today shocked to read a bunch of idiots have lobbied us to be part of AUYSH (for people who don’t know AUYSH- it is the clubbing of all magical medicine from India and one nonsense from Germany). This is what happens if people who are lobbying and in the politics of associations are uneducated and have a poor understanding of medicine.

There are only 2 types of medicine-1. Modern medicine and 2. traditional medicine. Modern medicine is an evolution of traditional medicine and it should be not called allopathy or English medicine. What do I mean by evolution of traditional medicine? Modern medicine developed as we find more science in our traditional methods of treating. Classical example is treatment of malaria using chloroquine.  It is a common method of treating malaria derived from traditional knowledge and it transformed into modern medicine because it has been put through scientific rigor rather than just believing it to be the treatment because someone in the 2 century or some sidhar wrote it in 10 century.  

Physiotherapy is part of modern medicine. Why? Because we don’t believe in the five element theory of disease as in acupuncture or Ayurveda, or some fantastic pseudo-science –“like cures like” (homeopathy) or vertebral subulxation (magic from north America- chiropractic)  and follow modern physiology. We do trials to confirm and deny our science (read Cochrane summaries).  But you will not read those in traditional medicine, were the founders and the bibles which are written in a different era is still considered as the truth.  Modern medicine is dynamic; it changes with new findings and research.

So, pray who are we. We are should be and are department of physical medicine and rehabilitation.  We are part of a team of health provider including physicians, surgeons (as in acute physical medicine- example, cardiorespiratory PT), with OT, clinical psychologist and others as in case of Neuro-rehabilitation. I hope I don’t have to elaborate on ortho-PT (where I believe we should be primary health care providers in case of cold orthopedics and part of the team in traumatolgy). We should be striving for these issues. We should learn to be primary source of knowledge in these areas and work as part of the medical team. A classical example is dental. T they are part of the modern medicine and at the same time have created a knowledge base of dentistry which is unique to them (remember some of their principles will be similar to ortho).

Sensible people should educate our presidents, prime ministers and other cabinet ministers of our association

http://static.fjcdn.com/pictures/Amen_b6a004_4599236.png