Physiotherapy January 2002/vol 88/no 1

Letters

IMAGINE reading a drug trial whichfound that a painkiller or an anti-inflammatory effectively relieved painin any body part except one! Doctors(and, I hope, therapists) wouldnaturally view such a finding withsuspicion at best, and derision at worst.This is because we would be hardpressed to come up with a mechanismof action for a treatment that omitted a particular body part in this way.However, we do not seem to apply thesame level of common sense toresearch findings from thephysiotherapy literature. I’m sure wecan all recall examples from trainingwhen our tutors suggested treatmentswould be beneficial for one joint, yet of no benefit for another. The recommendations were oftencontradictory and based on badscience, or no science at all.

I can remember the feeling ofunease with which I diligently recordedthese gems of expertise from exaltedand experienced clinicians. I had thisfeeling because I could not think ofany anatomical or physiologicalmechanism that would make sense ofthe advice I was receiving. What was sodifferent about the connective tissue inthe knee and elbow that necessitatedcompletely different modalities?

Physiotherapy is now producingmore research than ever before. We need to get into the habit ofjudging whether an experimental

outcome is congruent with our basicand applied science before we includeit in our knowledge base. We shouldnot absorb statistically significantresults without measuring them againstthe benchmark of common andscientific sense. In an article byNäslund in the August 2001 issue ofPhysiotherapy the author asserted thatLLLT had been shown to be ineffectivein the treatment of pain (based on anextensive meta-analysis by De Bie,1998) except for knee pain. I cannotthink of any difference between kneetissue and the tissues of other bodyparts investigated that would explainthis finding.

The more scientific and logicalresponse is to adjudge the apparentexemption for knee pain as an error ora scientific/statistical aberration. The wrong response would be to writein my clinical notebook: ‘Laser: goodfor knees, no good for elbows, wrists,ankles …’ and thus add to thecirculation of dubious science to juniortherapists.

Like many of the problems in thephysiotherapy knowledge base thisproblem is perpetuated by our cultureof poor research consumption skills. In a later article in the same issue ofPhysiotherapy, Metcalfe and colleaguesfound that although 96.9% ofphysiotherapists agreed that research isimportant for the profession, almost70% of physiotherapists felt they were

not equipped to evaluate research and80% felt they did not understandstatistical methodologies.

The importance of literatureappraisal and related skills has beenobvious for many years now. It is timeour deficit in training was addressedseriously. In particular, it is timeschools taught the skills of researchconsumption properly so that thisappalling situation improves.

Richard Shortall PTAlbuquerque, USA

References

de Bie, R, Verhagen, A, Lenssen, A, de Vet, H, van den Wildenberg, F,Kootstra, G and Knipschild, P (1998).‘Efficacy of 904 nm laser therapy in themanagement of musculoskeletaldisorders: A systematic review’, PhysicalTherapy Reviews, 3, 59-72.

Näslund, J (2001). ‘Modes of sensorystimulation: Clinical trials andphysiological aspects’, Physiotherapy, 87,8, 413-423.

Metcalfe, C, Lewin, R, Wisher, S,Perry, S, Bannigan, K and KlaberMoffett, J (2001). ‘Barriers toimplementing the evidence base infour NHS therapies: Dietitians,occupational therapists,physiotherapists, speech and languagetherapists’, Physiotherapy, 87, 8, 432-441.

Physiotherapists Must Improve their Research Appraisal Skills

I FOUND one of the most interestingaspects of David Jackson’s article onthe management of low back pain(Jackson, 2001) was the list regardingthe use of various modalities in thetreatment of LBP. This indicated thatlumbar traction was used only once as atreatment modality, interferential notat all and there was no mention ofmassage.

The latter two points seemparticularly relevant when one viewsthe findings of Van der Valk et al

(1995) where those two modalitieswere used much more frequently. It would have been very interesting to see why these apparent changingpatterns have come about; were theydue to fashion, evidence-basedfindings, cost or other issues?

Jackson also focuses on the cost to a service of non-attendance. I am leftwondering, reflecting on his list, about

References

Jackson, D A (2001). ‘How is low backpain managed,?’ Physiotherapy, 87, 11,573-581.

the cost associated with the many idlelumbar traction and interferentialmachines. Both aspects would makefascinating research areas.

Simon RouseMCSPYork

Van der Valk, R W A, Dekker, J and VanBaar, M E (1995). ‘Physical therapy forpatients with back pain’, Physiotherapy,81, 345-351.

Changing Treatments

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