Dear Kevin,

You have rightly hilighted the flaws in randomised controled trials.
However you do seem to be very strongly opposed to this type of research.  I
hope if any one else comments or enquires about any other sort of research
that you will be equally critical.  As far as I can make out studying the
effect of interventions on humans is fraught with problems due to the
complexity, unpredictability and individuality of each and every one of us.
The only conclusion one can draw from hundreds of years of studying humans
is that by studying them you change the nature of what you are studying to a
greater or lesser degree every time.  However this does not mean that you do
not learn anything from a particular study.  

> -----Original Message-----
> From:	kevin reese [SMTP:[log in to unmask]]
> Sent:	30 November 1999 17:28
> To:	[log in to unmask]
> Subject:	Re: RCT
> 
> Dear Renee
> 
> I am aware of both how the RCT works and what the rejection of the nul
> hypothesis at the 5 percent threshold means. The point I am trying to make
> is the appropriateness to therapy research and its consequent
> misinterpretation; which I have seen many times amongst my colleagues, eg
> there is not a statistical significance therefore this modality does not
> work. Wrong conclusion, commonly made.
> 
> Regards Kevin
> -----Original Message-----
> From: Renee Cordrey <[log in to unmask]>
> To: [log in to unmask] <[log in to unmask]>
> Date: 30 November 1999 03:41
> Subject: Re: RCT
> 
> 
> >Kevin,
> >
> >First, what is SSED?
> >
> >Secondly, when you mention 5% threshold limit in point two, do you mean
> >rejecting  the hypothesis at an alpha of .05?  That does not mean that
> the
> >intervention worked 95% of the time, or that it got people "95% of the
> way."
> >It means that the difference between groups  has only a 5% chance of
> being
> >incorrect.  The size of the difference is irrelevant.
> >
> >Renee
> >
> >kevin reese wrote:
> >>
> >> Dear All
> >>
> >> Thanks for all your input and yes Maggie I was being a bit
> mischievious;
> >> still it did provoke an interesting debate.
> >>
> >> Firstly I am not all out against RCT, I just think some quarters in
> medicine
> >> see it as the be all and end all of research, not recognising how its
> >> weaknesses and misuse lead to difficulties. To answer Renee; the flaws
> I
> see
> >> are
> >>
> >> 1 It is a deductive philosophy which can lead to misinterpretations of
> fact.
> >> Sure all philosophical arguments are flawed, merits and downsides exist
> for
> >> all. Generally when reading philosophy I rarely see one approach
> singled
> out
> >> as the gold standard.
> >>
> >> 2 The 5 percent threshold limit was developed for evaluating crop
> >> germination and not patient outcome. How many clinicians would discard
> a
> >> treatment with only a 94 percent efficacy?. Yes I know I am confusing
> >> clinical and statistical significance, but RCT seems to do this is
> clinical
> >> practice; reducing complicated systems into single fact answers.
> >>
> >> 3 Inclusion and exclusion criterion; almost impossible to match in
> >> complicated systems such as individuals illustrated by spectacular
> mistakes
> >> eg philidamide.
> >>
> >> I am sure this is enough to provoke further debate; please do not
> polarise
> >> me into the man who hates RCT, I just tend to question when people say
> why
> >> something is such, without providing proof or rationale. I also believe
> SSED
> >> matches many aspects of therapy research better than RCT, but as it is
> not
> >> recognised as gold standard by the medics it continues to retard
> resources
> >> for therapy research.
> >>
> >> Warm Regards Kevin
> >> -----Original Message-----
> >> From: M.Campbell <[log in to unmask]>
> >> To: [log in to unmask] <[log in to unmask]>
> >> Date: 28 November 1999 23:08
> >> Subject: Re: RCT
> >>
> >> >In message <000101bf39a9$8a9f1180$7c45a8c2@kevinree>, kevin reese
> >> ><[log in to unmask]> writes
> >> >>Dear Lists
> >> >>
> >> >>WITH APOLOGIES FOR CROSS REFERENCING
> >> >>
> >> >>I am curious to know why the RCT is considered a Gold Standard when
> >> >>conducting therapy research. Any thoughts ?
> >> >>
> >> >>Kevin Reese PT UK.
> >> >>
> >> >Methinks you are a little mischievous Kevin.
> >> >
> >> >All research methods have their strengths and weaknesses.  Weaknesses
> >> >especially when applied to the wrong question.
> >> >
> >> >The problem with RCT's in the case of many PT interventions is that
> you
> >> >may just control out the very factor that makes the difference in the
> >> >therapeutic process.  However, if you have a full understanding of the
> >> >subject under enquiry and you want to test the outcome of two
> >> >interventions with the objective of seeing which produces the best
> >> >outcome over a large group of individuals then an RCT may be an
> >> >appropriate choice.......
> >> >
> >> >In many rehab areas - for instance my own speciality area of traumatic
> >> >brain injury - many of the questions have yet to be fully defined
> and/or
> >> >the potential contributory factors to any outcome are so many to make
> >> >the results of an RCT clinically meaningless.
> >> >
> >> >In many cases I think practice development would be served better by
> >> >*documenting* the genesis of treatment strategies that are based on
> >> >basic science, i.e. hypothesis development from first principles, to
> >> >demonstrate that our interventions have science behind them and then
> are
> >> >differentially applied to individual situations.  I suppose I would
> >> >argue for sound hypothesis development from formal research or formal
> >> >documentation of the root of frequently used theories, followed by
> >> >multiple single case experiments that would generate more qualitative
> >> >information as well as having the potential to be grouped over time.
> >> >
> >> >Whatever we do we must have the confidence to argue for research
> design
> >> >appropriate to the question - and remember that RCT's have their roots
> >> >in agricultural research where all perameters could be controlled.
> >> >--
> >> >Maggie Campbell
> >> >Neurophysiotherapist
> >> >
> >> >[log in to unmask]
> >> >
> >> >+44 (0)114 268 6963
> >> >Sheffield UK
> >> >
> >> >and
> >> >Research co-ordinator
> >> >Directorate of Professional Services
> >> >Royal Hallamshire Hospital, Sheffield
> >> >                (0)114 271 1750 (voice-mail)
> >> >[log in to unmask]


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