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

The importance of using the right language while talking science

The importance of using the right language while talking science

One of the biggest concern for me in PT (especially in India) is the advent of newer terminologies in describing- well either imaginary things or already existing things.

1.       The first example is a classic- the trigger point release. When I went to college it was called like in any sensible medical literature as tender spot. Along came the 2000s and with than came in fancy treatment-  TRp release.

The first issue is whether it is the Ashi point as they called in magic (I am referring to acupuncture) or trigger point as they call in some neo-magic (I am referring to chiro or something) is –why do we have to call it as trigger point and not tenderness. There are some half baked studies which looked into the histopathology of it and proven- well we don’t know for sure. However, there are also many studies which have consistently proven that reliability of finding them poor at the best. The next issue with the word release- what the hell is wrong with us to call something as release. These words come from a magical treatment called chiropractors – who studied magic rather than physiology when they wrote the term. However, we now are in the era of -free or easy access to knowledge, and we should know better. Muscle or pain is not something you release, it is such a complex phenomenon it is scholars are grappling with it for many years, but we are just, “I released the trigger point and the patient is alright”. This reflects very poorly on worth, we are more intelligent then that. 

                So, pray what should we refer to ask my friend? Well, the muscles relaxes, beautifully named as “Hold and relax” by Knott and Voss. Relaxation is a phenomenon of the muscle- not release. As for trigger point, well pray –Sarwathi visits us and we all read medical literature other than Facebook posts.

Of course there are 100s of therapist who are going to say- well this guy is a moron, I have seen it, I have seen people getting better etc.

     

2.       Bone has eroded- (you know what we say in our vernacular). It is high time we talk about back pain, OA as a disease not as pathology. Talking it as a p athology makes you want to change the pathology, it creates so much anxiety in the patients mind. We need to have a better language in patient education regarding these diseases. Just, keep the x-ray or MRI in the cover rather than seeing it.

3.       Facebook- it is a proper noun- it cannot be called as முக- நூல்- come on people Hariohm is Hariohm in any language. Thank god we did not translate- google,  cognizant (which again can be translated unlike google)

4.            

My 2 cents on associations of physiotherapy

I usually don’t write about any of the associations in India or Tamil Nadu (TN). Reason one, well I have a life. But this Saturday afternoon, did not have anything to say so- here is my take on our precious associations.

The first thing I find in TN is there are 2 many associations. The general feeling I get is everyone seem to think they are here to lead and they don’t want to follow any one. The second is everyone thinks there aim is more – how do I put it- has a higher purpose.

The first thing I see all the associations do is –well this is in vogue for the past few years – is conduct a National conference. I don’t have anything against it – but I can distinctively remember in the late 90s we all complained that is what IAP did and nothing else. Well the all the associations have fallen into the same pattern. As we say in non-linear theory- they have all fallen into the same attractor state.

The next thing I remember what all the association meetings were about:

1.       Getting government job

2.       Getting a council

3.       Talking bad about-The Man (the one person who is stopping  us from achieving the goal)

I have not gone to any meeting for quite some time but, I am assuming this is what is discussed and also from all the cry babies writing in face book.  Well what is wrong you ask me? Well don’t worry any of the people who took the time to read this is going to get it. We are more in numbers and the government jobs are never going to enough. Please understand medical economics if you are one of those “leaders”. The government’s policy on health is complex and it depends on burden of illness, resource and who can lobby well. So don’t be gullible in thinking 10- 200 people are going to get you to change all that easily.

Getting the council, Well a must need for PTs but it is not a panacea for all our woes. It is not going to bring more jobs, more money, not change your salary if you are working even in a college. Come on people read market economy; we have a right wing government in the centre and a centre to right in TN.

Well not writing about the last one because- I may be the man in the next meeting who is stopping you from growing.

What do I think associations should do?

Well the good things first- I see some association doing clinical meeting or CME. AS you can imagine I think that is a wonderful step. However, my personal opinion is get people from your own city, own association to do the talk. (This is also for the conferences) Why call some idiot from Mumbai or some place else).

Lots of associations have a dedicated people –who are leaders and follower- but I just can’t get over the feeling there is a lack in understanding of rudimentary things. I can remember being like that also after when I came out of college. Use them for something constrictive and think real issues- like training us to do be first contact practioners before asking for that.

Stop telling us diploma is bad, correspondence course is bad- of course we know that, more importantly that is how most of the regular colleges are running. Sad part is some of the “leader” have got there degree by not stepping into the college even to use the loo.

Stop being talk shops. I see many of the association becoming talk shops-getting the troops rallied up all the bull shit but with no substance. The common thing I see people talk is the universal cliché since Marx times- “Unity”. When the great Marx said unity he wrote a 3 volume book- which after trying for 7 years could not understand it- sold it back to the old book store. But most of the time when I see therapist say it is without doubt- without any substances. Why do you want us to be in union? Fight for what? What right am i not given? What is your goal? If your goal is get united and fight for unity, justice, get a council, get us jobs- well may be I will join justice the league  and fight crime at night along with superman et al.   

Of course there are also other association/ cults in this mess- the NDT cult, Mulligan cult and the overall manual therapist cult-well don’t get me started on those idiots.

Disclaimer: I have participated in some associations functioning before realizing –what a waste of my energy and intellect.

Homer Simpson- Old people don't need companionship. They need to be isolated and studied so it can be determined what nutrients they have that might be extracted for our personal use.