The longer I practice and the more I learn through reading the research about various interventions, I look at some treatments that are being delivered and say, REALLY!?! But that gets me wondering: “What treatment does my patient REALLY need?” I’m not asking what treatments have been shown in study to get people better or what treatments that I’ve used before and I’ve noticed they got better. I’m asking a deeper question, what treatment do they really, really need. I mean the type of treatment that if I did not provide it, the patient most likely would not get better and suffer more because I withheld the intervention.
I’m curious to see what the comments section will bring as we debate a question like this. It’s a question without evidence to definitively say one way or the other which treatment is really needed all the time. (We probably never will. When treating a patient, we are treating a n=1 and trying to answer that patient’s questions. It’s not the same as answering a research question)
How can a study say it doesn’t work, when I’ve done it on patients and they tell me it works? Or flip it, in those cases where a study says it works, but it didn’t when you tried it with a patient.
While there is some research in some areas they may be pointing us more one direction than another. I frequently come across various research articles on interventions (IASTM, PRT, Manual Therapy and Exercise, TDN) that I wonder what conclusion the therapist reading it come to after reading it? Does it work on not work? How can a study say it doesn’t work, when I’ve done it on patients and they tell me it works? Or flip it, in those cases where a study says it works, but it didn’t when you tried it with a patient. It gets confusing when one study says something works as good as something else (stabilization exercises as good as manual therapy) and then another seems to say that they are different (manual therapy better than spinal stabilization). Of course with understanding the evidence, the devil is in the details (what questions are the researchers seeking, how good was the study, what are the biases, could the data be interpreted differently from what the authors came up with). To be an evidence based practitioner we need to have a critical eye when we read and apply research to our clinical practice and ask more questions. It is vital to the growth of our profession and the health of our patients and society.
I’m not suggesting some form of nihilistic view that nothing works and everything is the same so don’t do anything or the “I know my patients get better so I don’t need to read the research” attitude. I’m just challenging us to think and reflect on our treatments, if it was REALLY needed for my person in pain. Could I cut out a few things and still get the same result (this saves everyone time and money)? Should I spend more time on some things and less on others (this may expedite and enhance results)? Do I think through what the patient might want to do or believe they should do? Do I consider what they will be motivated to do? How about if they have the resources, skill, and knowledge to do what I’m asking them?
In regards to certainty with treatment interventions, I think we can be certain there is not ONE treatment that will work with everyone (even though there are plenty of advertisements telling us there is). I like to put treatment interventions into three categories. First, there are some treatments that research has shown that are better for most people with certain conditions. Second, there are some interventions that from a research perspective get similar results as others in general. Third, there are the interventions that seem to be centered mostly around placebo effects when patients get better when we provide them. We need to provide more of the first, used shared decision making with patients with the second, and work to eliminate the third.
via Dr. Kory Zimney, DPT
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Keeping it Eclectic...