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In respect to the collective good, I find it appropriate to make 
this answer public and not engage in personal attacks, since the 
issue was raised in a public domain of the mailbase lists.
I have made individual responses to Mr. Gray's contiuance of the 
debate below. 

Date sent:        18 Oct 2000 05:35:59 -0700
To:               [log in to unmask]
From:             Bruce Gray <[log in to unmask]>
Subject:          Re: FW: evidence based practice...

Hi Panos


> 
> Colleagues, 
> 
> first of all, thanks to Kam, for bringing this issue to our 
> attention. 
> 
> It is a very interesting thesis that our colleague from Australia
> proposes. 
> 
>>In the first instance it sounds quite rational, it is the second
>>reading that lets it down. Lets examine the Evidence that Bruce 
puts
> >forward in his (educated?) choice. The first issue of concern is his
> >isolation. Being the sole practitioner can very well serve one to
>> make such decisions. Nevertheless a decision based upon one's
> >predilections hardly constitutes an educated decision. The point
>> 'electrotherapy sucks' now merits closer scrutiny.


>this is a non sequitur Panos. You assume because I am a sole
>practitioner that I now or previously have no contact with other
>professionals. you also assume my stance is a predilection despite 
>my reference to invivo studies.

Dear Sir, I did not make any assumptions that you did not allow from 
your message. My mention to your current lack of company was made in 
order to highlight that you are able to impose such decisions without 
any particular debate. As for reference in invivo studies, do you 
include rat and rabbit ones in this category? In my book they are 
also invivo and very good ones at that. 

>just to fill you in, I have a B.Sc with first class honours in
>neurophysiology and a B.Phty from the University of Qld, a champion 
>of evidence based practice, if you read the literature. I also treat 
>at least 150 ppl a week through OPD and clinics (orthopaedic, 
>fracture, hand). in this setting, whatever oportunity I miss out on 
>applying electrotherapy 150x/week, I gain the opportunity of 
>recognising that what ppl do at home 3-7x/day is far more relevant 
>then what happens in OPD or clinic 2x/week, hence the thrust of my 
>argument- i.e. that patients don't think electrotherapy is something 
>that it isn't.

One does not fail to be impressed by the width and breadth of your 
experience. Nevertheless this does not qualify one automatically to 
authority in all aspects of research and evidence. From the 
description you provide of the service to your patients, you hardly 
have time to evaluate all aspects of practice.  

>> 
>> If one cared to evaluate the scientific evidence for the majority 
>>of modalities used by physiotherapists, medics and other 
>>professionals
> >in healthcare, one could very easily come to that same conclusion
> >for a great number of them. 
> 

>this is a sloppy generalisation Panos.

Sloppy is my middle name, just ask my wife!

> "Most" medical therapy does
>have evidence to support it. Maybe you should work in an ICU unit to
>clear your mind on the benefits of medical practise.

 Perhaps you would like to refer to Sackett's work on the issue of 
support of medical practice by pragrmatic evidence and a recent 
editorial in Progress in Brain Research (peculiarly enough dedicated 
to mind-body medicine, what are these hard core scientists think 
they're doing??) which highlights the issues of what supports medical 
practice. 

> If I ever have 
>an angina attack I sure won't reach for an interferential machine to
>ease the pain. As a matter of fact if you read my argument again I
>didn't mention pain, I referred to leucocyte  and fibroblast
>activity. 

I only need to refer you to Ballegaard et a's work on angina and its 
response to acupuncture (a medline search may come handy at this 
point, I don't intend to insult the readership's intelligence by 
doing one for them). As for leucocyte and fibroblast activity, were 
one to look at the effects of electrostimulation upon proliferation 
rates of these cells, one may be surprised of what is out there. Not 
to mention rates of cortisol increase following electrostimulation 
and the effects of oxytocin in healing. Nevertheless, I am sure that 
you have a lot of literature support of the modalities you hold dear.

>As a rational being in search of the truth, I seek to deal 
>with the cause of distress, not it's end symptoms. If you want to 
>steam ahead and use electrotherapy for pain relief in preference to 
>stopping chronic cell damage or inability to heal, then go ahead.

After all, I am out there for worsening practice and influencing 
healthcare towards non-effectiveness. The work of Liebskind on the 
effect of pain upon the immune system is celebrated in a free, online 
volume of the PNAS 
(http://www.pnas.org/content/vol96/issue14/#COLLOQUIUM) 
should one chose to form an informed opinion about pain and 
healing.

>> Nevertheless, when it comes to electrotherapy, there seems to be a
>> contradiction: compared to modalities such as manual therapy,
> >exercise therapy, McKenzie, Maitland and Cyriax approaches,
> >electrotherapy (in the form of electrical stimulation- Tens,
> >electroacupuncture, acupuncture etc) has a great wealth of evidence
> >as to its physiological effects. 
>> 

>I feel like I am tryng to preach to a blind zealot here Panos.

The words 'kettle' and 'pot' spring to mind reading this.
 
>Sharpen your senses lad. there is a dearth of invivo evidence. screw 
>the physiological evidence, it rarely crosses over into a 
>significant clinical effect, especially when the average appn of 
>electrotherapy in a public hospital setting is 15 minutes a week, 
>and 2x15mins a week in a private practise. 

Now, that is reasonable argumentation between professionals. Not only 
substantiated but eloquent as well. The national average of 
application is well below the recommended dose that research (that 
'screwable' physiological studies, boy this is weird!) dictates. One 
may start to see that it is not the modality that needs criticised, 
perhaps its application and the system that supports it.


>> It is of course, necessary to make sure that one does understand
>> that physiological effects do not necessarily mean clinical 
effects.
> >But again, there are a multitude of studies which do provide some
> >evidence for the efficacy of electrostimulation in conditions other
> >than just pain (eg. wound healing, Lundeberg, ScandJRehabMed, 1993).
>> Admittedly, evidence for US or PSWD and Laser are scarcer and of
> >lesser quality, although there are some evidence to support the use
> >of these modalities for conditions other than pain.
> >

>some evidence....? and as I inferred, this is not double blind 
>placebo controlled cross over designed. rarely if ever have the 
>effects of electrotherapy been put up against the effects of a 
>sensible ice/heat rest/movement regime. 

Sorry to be the one to point this out Sir, but you might want to 
consider reading somewhat wider than you currently do. 

>> The alarming message I picked up from this report from Mr. Gray is
>> the belief that pharmacological agents and their prescription
>> represents better quality of care for the patient and is 
indicative
>> of one's level of training. Perhaps Mr. Gray is unaware of the
>> reports that 40000 people in the UK are hospitalised as a result 
of
>> NSAID use and 2000 of them do not get out of there alive. He must
>> also be unaware of the reports which state that chronic use of
> >NSAIDS by people with arthritis results in an increase in the rate
> >of degeneration and resulting disability. Not to mention that
> >(Lazarou et al, 1997, JAMA) pharmacological agents are responsible
> >for 400000 deaths in the US annually.
>> 


>so let's spend more taxpayers' money refining pharmaceuticals 
>instead of spending it on public hospital physios delving out 
>electrotherapy.

this is truly inspiring. A whole set of health professionals replaced
by a pill. a day for all of us to revere that would be and quite a
realistic expectation you may agree.

> Panos if you understood someting about contemporary 
>pharmaceutical trends you might recognise how research is able to 
>design better drugs with higher specific receptor affinities that 
>increasingly are having less side effects. I would prefer capital 
>was spent on this than on the dubious fuzzy effects of putting EMR 
>or electrial current into the body from the skin surface.

Funny you chose to mention receptor specificity, I was in a lecture 
just last weekend by a very respected neuropharmacologist, Prof. 
Zieglganzberger, who pointed out that the higher the receptor 
specificity the worse the effects (in terms of side effects and 
mortality) for the patient. It has been a medical history truth that 
the 'dirtier' the drug the better its application. Interestingly, 
this man now choses to treat his patients with St. John's wort 
instead of Prozac for mild depression (and before there is any 
embarassment, one should check the Cochrane library for the SR which 
compares the effectiveness of both in this condition). Yet, the magic 
tablet may await to be discovered, if you ever became in charge of 
NHS R&D spending.

>A case in point is the lower side effects of celebrex compared to
>voltaren. 

Only one comment: BMJ 1998;316:333-8, & BMJ 2000;320:1058-61

>by your logic Panos all hospitals should be closed down as a health
>risk. maybe you suggest we all get a good dose of daily 
>electrotherapy to help us attain immortality?

You have an amazing capacity for interpretation of one's writing, 
I'll give you that. My words exactly (thanks, by the way, for 
attributing higher intellectual properties such as 'logic' to me).

> if degeneration rates 
>rise on NSAIDS then it is partly due to patients exercising more in
>the well controlled absence of pain. you would prefer ppl had less
>effective pain relief so they stayed less active. or that we slow
>down finding the true cause of arthritis so that we can keep giving
>patients placebo machines.

That is an interesting interpretation of scientific evidence. I am 
surprised how others never thought about that. I can imagine 60yr 
olds with OA hip and knee, gobbling a couple of iboprufens and 
joining the london marathon.
I have not spoken at all about 'placebo' machines. My thesis is that 
the therapeutic interaction alone has a beneficial effect to the 
patient and the therapist. This (non-specific) effect has been 
condemned as placebo and any therapeutic outcome has been attributed 
to science. Well, current thought challenges this belief and 
advocates the maximization of such effects for the benefit of the 
patient. 

>I am amazed you don't espouse drinking urine as well- this also had
>great placebo effects when preached by Indian Yogis.

Crossed my mind some nights in the pub, it could make a pint last all 
night. 

>> I also was alarmed by the dismissal of the placebo effect as a
>> therapeutic agent. All types of treatment have an element of
>> non-specific treatment effect built in them and that must be
>> maximised to the benefit of the patients. Why should that become a
>> sin and not credit to the clinician who uses it I fail to
>> understand. Placebo is a research problem and a clinical blessing,
>> anyone who choses to ignore this should perhaps re-evaluate their
>> clinical reasoning and choices, that is my opinion.
>> 

>If I am to lie straight in bed at night with an easy conscience, I
>will never dress up the placebo effect as anything other than what 
>it is. Panos, I say that you are patronising and belittling your 
>patients if you use electrotherapy as placebo. That is anathema to 
>me. It is not medicine and certainly not science. 

So you would prefer to strip all your therapeutic interactions from 
non-specific effects and rely solely upon therapeutic effects of 
specific modalities? I have utmost respect for my patients and, if 
anything, empathy for their predicament. It would be a mortal sin 
for me to capitalize upon their misfortune and 'fool' them. My 
reasoning is that I can maximize my therapeutic effects by combining 
maximum returns from 'specific' and 'non-specific' effects of the 
modalities that I employ. I don't believe I am even answering this.

 >If that is the level you think on, then I won't argue with you
>further. If you don't have the training, subtlety, communciation
>skills, maturity, or persona to educate and persuade a patient to
>comply with a home care and exercise program then I can understand 
>you resorting to using electrotherapy for its placebo effects. 

Yet again a level of uneducated speculation emerges. You may want to 
refer to recent publications on the issue of compliance to home 
exercise programmes and the predictors of outcome of these in chronic 
pain and degenerative disorder patients. But then again I am a 
personality-devoid uneducated, imature ignoramus, how do I know?

>As a physiotherapist in the 21st Century I consider it my duty to
>educate patients about pathological processes and what will most 
>cost and time effectively aid this; not keep them in the dark and 
>feed them placebos. That may work where you live, but many of my 
>patients are well educated & not vulnerable, and won't be sold snake 
>oil. 

One of my most favourable medicaments is snake oil, my patients grow 
hair, become younger and more handsome after its consumption. The 
majority of them being university academics, do like living in the 
dark and the UK has a long history of believing in ineffective 
practices. Please...
I consider my duty to educate the future of our profession to make 
sound clinical judgment based upon experience, individual patients 
and science, not feed them placebos whilst kept in dark confined 
spaces.

>> So, being somewhat different in stature and demeanor of an old 
woman
>> which knows no better, I seem to fail to agree with mr. Gray's
>> largely biased, uneducated and violent message to throw away my
>> 'ping' machines. The oxymoron here is that Mr. Gray also urges to
>> ...'choose instead to never compromise on finding truth again...' 
a
>> dictum he himself just violated by posting his message. 
>> 


>Good luck in clinging to your religious faith in the power of
>transduced electrical current as the pure source of life essence.

Religious is something least likely to be characterised as, by those 
who know me. My only thesis is that any argument should be based upon 
one's educated opinion and not follow the populist approach. Should 
you chose to spend some time, as all of us should do and most of us 
have done, evaluating the relevant evidence prior to expressing such 
radical opinions, you may find that belief will be replaced with 
healthy questioning and reflection. That is what therapy should be 
characterised by, not rigidity. I always seek others light and in 
that spirit I will leave you with some of my favorite quotes from 
admirable contributors to civilization, that I frequently use in my 
lectures.

Great spirits have always found violent opposition from mediocre
minds. The latter cannot understand it when a man does not
thoughtlessly submit to hereditary prejudices, but honestly and
courageously uses his intelligence. 
Albert Einstein

Physiotherapy is not a technical occupation where understanding of 
the tools we employ, beyond how to use them is unnecessary. As a
profession we are charged with using our tools and strategies
(including research) with a clear understanding of the expected
outcomes and the assumptions, conditions and rules of using these
tools and strategies.
Higgs and Titchen, 1998

A blind man knows he cannot see and is glad to be led, though it be by
a dog; but he that is blind in his understanding which is the worse
blindness of all, believes he sees as the best and scorns a guide.

I do hope that personal frustration and reciprocation of compliment 
has been kept to a minimum and that the debate does resume in its 
academic, original form. 
Apologies if any of the members of the fora to which this is 
distributed find this disturbing, it is not meant to be. 

regards,
P. Barlas, BSc(Hons) PDD, DPhil, MCSP, SRP, Lic.Ac
Senior Lecturer,
Physiotherapy Subject Group,
Coventry University,
Priory Street,
Coventry, CV1 5FB
Tel: 024-76-888980
Fax: 024-76-888020
e-mail: [log in to unmask]
http://www.hss.coventry.ac.uk/physio/


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