Although the following comments may, at first, sound like an argument against
research, the message is for more research of every type.
The controversy about "evidence-based" practice has been hot with discussion for
many years. One of the best papers on the subject, from my point of view, is the
Sir Austin Bradford Hill 1965 address: The environment and disease: Association or
causation. From S. Greenland Evolution of Epidemiologic Ideas: Annotated Readings
on Concepts and Methods, Epidemiologic Resources Inc 1987.
Change the title to read "The treatment and the response: Association or
causation"
Sir Bradford Hill makes an argument that strength of association, consistency of
association, specificity of result, temporal relationships, dose response
relationships, biological plausibility, coherence with other cause and effect
relationships, and experimental results are justifications/evidence for cause and
effect. Sir Bradford Hill makes the point that none of the categories he describes
is infallable, it is the sum of the component parts that strengthen the evidence.
"Evidence-based" practice, as it seems to be currently practiced, only focuses on
a small part of this process. At the present time, there appears to be little
respect for the large amount of preliminary information gathering required before
longitudinal prospective trials are initiated. For example, it would really help
if we could identify a relatively homogenous group of patients in a back pain
study.
My biggest problem with "evidence based" practice, as it is practiced, is that
there are no mechanisms to generalize to a specific patient. Kerridge et al.
conclude that crude application of results of clinical trials to individual care
may be detrimental.
Kerridge, Lowe and Henry. Ethics and evidence based medicine BMJ
1998;316:1151-1153
Tonelli (1998, The philosophical limits of evidence-based medicine. Academic
Medicine, 73(12)1234-1240) makes similar arguments.
There are many interpretations of how to operationalize "evidence based" practice,
but by rating the standards of evidence the proponents are placing a value
judgement on the types of information used to justify clinical practice. The types
of research that are rated higher may be in conflict with our clinical needs and
the needs of the patient.
Murray
*-*-*-*-*-*-*-*-*-*
Murray Maitland
Assistant Professor
School of Physical Therapy
University of South Florida
12901 N Bruce B. Downs Blvd
MDC 077
Tampa Fl USA
33612-4766
Jackie Waterfield wrote:
> Evidence based practice emphasies the judicious use of best
> external evidence, clinical expertise and patient
> preferences
> they do not expect you to put aside clinical reasoning
> thats how you make 'all sorts of evidence' work for you
> jackie
>
> On Tue, 15 Jan 2002 10:51:26 +1000 Henry Tsao
> <[log in to unmask]> wrote:
>
> > Doug,
> >
> > Yes, I do see your point about US. I guess I continue to use it regardless
> > of the evidence for the old clients who believe that the machine with the
> > gel gets rid off their pain :D Even if it is just placebo, if it is what the
> > patient wants and makes the patients feel better, then I am not going to
> > ignore this effect. Apart from this, I do not use it in my other patients
> > unless it is specifically requested.
> >
> > U/S has been used for a long time, but has only come under strict and close
> > scrutiny in recent days, and I think we can say this to be true for most
> > physiotherapy techniques. It would be interesting however to see
> > replications of those studies published in physical therapy 2001 on the
> > effects of U/S in the near future. As we all know, it is a study's
> > reproducibility that strengthens its evidence.
> >
> > The article that I mentioned in Manual Therapy November 2001 is entitled
> > "Evidence-based practice - getting a grip and finding a balance." One of the
> > statements made were:
> >
> > "We have a lot of evidence to gather, a lot of ground to make up.
> > Importantly, we must avoid the "evidence-based practice technique syndrome"
> > where every patient with a certain diagnostic label, for example low back
> > pain... if clinicians do this... clinical reasoning skills will be lost and
> > clinicians themselves will become little more than technicians who can be
> > replaced by a cheaper workforce."
> >
> > Henry***
> >
> >
> > _________________________________________________________________
> > Get your FREE download of MSN Explorer at http://explorer.msn.com/intl.asp.
>
> ----------------------
> Jackie Waterfield
> Department of Physiotherapy Studies
> Keele University
> Keele
> Staffs ST5 5BG
> Email:[log in to unmask]
> Tel: 01782 583537
Phone (813) 974-1666
Fax (813) 974-8915
email [log in to unmask]
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