Scientific research v’s common sense

So I had an interesting online ‘debate’ concerning a blog by a fellow physio Tom Goom aka the running physio which can be found here… http://runningphysio.wordpress.com/2012/07/20/research-isnt-everything/

His latest piece was on a recent documentary on the BBCs panorama programme called “The truth about Sports Science” in which they looked at the lack of scientific research that some sports companys use in the advertising and marketing claims they make around sports drinks, supplements and trainers etc.

The programme highlighted how selective (or rather biased) these company’s can be with research data to help ‘sell’ their products and back the claims they make, showing them to be far fetched and sometimes just untrue, but you have to be either a child or a complete naΓ―ve fool if you don’t think that any company or brand is not going to push the limits of any research to suit their needs and to promote and make their product more attractive to sell, that’s goes for all industry’s not just sports.

For example do you really think that a cream can reverse the ageing process and fill out your wrinkles…. those company’s stretch research so far that they practically claim they have found a cure for the ageing process.

But back on point, the debate last night was over Toms blog on not taking research to literally and sometimes we need to look behind the figures and analysis, as there is, especially in the medical world, a lot of conflict and contradiction in research

For example Tom again showed in another blog how the use of Glucosamine has had only two good independent studies one says it helps prevent arthritis, the other says it doesn’t. I come across this many times, like recently when I was looking into research on Isokinetic machines for testing professional football players leg muscle strength and ratios, the same contradiction in papers can be found, some studies show they can highlight a risk of injury, others don’t, this area really needs a systematic review by the way.

So where does this contradiction leave us the poor physio with the patient looking at us expecting us to make them better and give them the advise and the guidance they need when they are injured.

Well it can leave us in a very difficult position, but simply put we have to be guided by the research, but we also have to use our common sense, for instance my last blog on glute exercises, I know the research out there shows that the side lying exercises have been found by EMG electrode studies to get a stronger contraction of the glute medius muscle than the ones I recommend, but in my experience they aren’t as practical for a runner to do, thats common sense V’s research. My preferred exercises still work the glutes just not as much as the side lying versions, most my patients prefer them over the other ones and they get results.

I am a strong advocate for evidence based practice. I regularly read as much literature as my brain can handle on all things I do in my practice and follow the best practice guidelines,

For example I have abandoned practicing acupuncture after spending my own hard earned cash and investing my own time in training in it and using it for about a year, after some extensive background reading I have found the evidence to be extremely poor and unconvincing, and combine this with my own clinical experience of using it the vast majority of my patients had no positive outcomes, now some will argue that’s due to my poor technique or my lack of skill and experience in the art of acupuncture, it isn’t, it can’t be, it’s just putting a needle in, it doesn’t take that much skill and there’s no mystic art to it at all.

On the other side I have also changed my practice around treating tendionpathy, it was claimed that using exclusively eccentric loading exercise was superior, when we now know in early stages isometrics exercises seem to be more effective and then a combination of concentric and eccentric exercises that are carefully managing the levels of tendon loading gets better results, these are examples of evidence based practice.

Now a point about the use of anecdotal cases as research, as I’m sure someone will jump on this and start another debate claiming they have witnessed this and seen that in clinics etc etc, but it’s poor evidence and I’m afraid the plural of anecdote isn’t data, instead controlled un biased study and research is needed, yes I guess anecdotes do influence research, the ideas have to come from somewhere I guess, but until the research is done we cannot make any conclusions on them.

So that’s my ‘two penneth’ on research v’s common sense, in my opinion there has to be room for both in the physio and sports injury world, I will leave you with one of my favorite quotes…

Only in god we trust, all else must provide date

Now let’s see if this stimulates another lively debate

Cheers

Adam

 

2 thoughts on “Scientific research v’s common sense

  1. Hi Adam,
    Thanks for the interesting post. I think we all agree that the more solid evidence that we have the better our clinical decision making. That said, it is only one factor that is considered in our clinical reasoning process.

    Patient preferences must also be considered. For example, the evidence available may tell us that dry needling might provide a great outcome for condition x but if your patient does not wish to have needles then that treatment option is not the best for them. The same may be said for a whole range of interventions from manipulation to surgery.

    Another problem is the availability and applicability of the research. At present the gold standard appears to be double blinded, randomised, placebo controlled trials. While these may work reasonably well in the pharmaceutical industry they present some methodological challenges when dealing with musculoskeletal complaints.

    Suppose we wish to study the effect of an intervention on achilles tendinopathy. Are we able to gather an homogenous cohort of subjects with this problem? Are they all at the same stage of pathology or do we have a mix of reactive tendinopathies, tendon dysrepair and degenerative ones, not to mention the reactive tendinopathies on top of a background degenerative one? Our intervention is likely to change significantly depending on the stage of pathology.

    Similarly, is the intervention appropriate for that person? As it can be argued that the tendinopathy results from an inability to effectively manage load (usually too much but possibly stress shielded) it follows that addressing the origin of the load is imperative. Leaving aside training and recovery issues and looking simply at the biomechanical chain (again conflictive evidence as to causation but stronger support that certain movement patterns will cause increased loading on various structures, changes in EMG activity etc.), the faulty kinematics may vary from subject to subject. In some it may be more appropriate to address hip control, others the foot position for example.

    Therefore does our double blinded (if possible) RCT adequately account for this? Probably not. The usual way is to categorise them based on time – less than three months – acute, greater than three months – chronic. They then have different biomechanical factors influencing the condition and lastly they probably have very different requirements of the tendon e.g. someone doing triple jump requires a very different rehab than someone running a marathon as the demands on the tendon are so different. So we end up with anything but a uniform group of subjects.

    We then try to apply the same intervention to all of them. Should we expect to see much of an effect? Furthermore, most treatment approaches involve a number of interventions e.g. addressing some of the biomechanical faults, controlled loading through exercise, perhaps interventions to assist both of these e.g. Dynamic Taping, joint mobilisation, dry needling etc. etc. yet most research involves only one intervention due to the methodological challenges. I can see five people with patellar tendinopathy and treat all five very differently – the exercises may differ, the taping techniques may differ and so on.

    Tendinopathy may not be the best example as I think the leading researchers in this area are on top of this and are producing some thought provoking and paradigm shifting results.

    In the past however, the same has been done for LBP. For example, let’s take everyone with non specific LBP of greater than three months with no referral and stick them on traction (or any intervention). Now within this group a small number may respond well, some may get worse and a lot will probably do nothing. Statistically, there is no effect but if we can identify and classify the group that responded well and then study a uniform group of these people we may see that there is a strong effect.

    We therefore need to critically appraise the research and work to evolve our research methods and improve the classification of conditions.

    Sackett, who I believe ( I might be wrong) coined the term ‘Evidence Based Practice’ suggested that EBP should account for about 10% of the decision making process with the rest coming from clinical experience, the clinical situation and patient preference – food for thought.

    Cheers,
    Ryan Kendrick
    BPhty, MPhtySt.
    Musculoskeletal Physiotherapist

    • Hi Ryan

      Thanks for your comments, I totally agree with what your saying. I think this is a question that will continue to create debate with those that prefer to just use and follow the research and those that will use research together with other methods such as experience and anecdotal evidence.

      Cheers

      Adam

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