I feel that evidence-based practice is the cornerstone for achieving successful outcomes. Many of the courses I have taken over the years have been by guru types who do not back up their treatments with cold hard facts. In the past I have been reluctant to make changes in my clinical practice based on those courses and this is backed up by an earlier paper by Resnik and Hart (2003). With solid research I know both my patients and I will get results. Therefore, I am always trying to integrating many better methods of assessment and treatment. I am receptive to change and will continue to evolve
We have integrated more evidence-based testing of outcomes using the Oswestry and other outcome measures. We have done a far better job of classification of low back pain into the four subgroups based on the evidence. We are trying to integrate more cognitive based assessment and treatment for chronic pain and ensuring that these patients are heard. We are trying to disseminate information to our local medical community to highlight how research shows we can provide better outcomes at a lower cost.
Our medical system as a whole needs to change the way we manage low back pain. The studies by Fritz (2008, 2012, 2013) and Gellhorn et al (2010) clearly show how the there is a need for physical therapist to have an active role. When you consider the eagerness of physicians to order imaging studies and jump to conclusions based on the pathoanatomics of these studies it makes me sick. In fact, the term VOMIT has been used to describe these cases (Victim of medical imaging technology). Our system needs less costly imaging, which often takes time to complete, and quicker access to treating the impairments ,which is what we do.
There is clearly room for improvement for therapists too and it is sometimes difficult to change the mindset of practitioners who have practised in a certain way for an extended period of time. It is easy to take on a guru mentality when treatments seem to be effective and people keep coming back. We need to do better. What is very clear from the research in this course is that the way forward is to treat patients with manual therapy, exercise and our interaction with them. When patients feel heard they are more likely to buy in to our treatment plan. If they are more adherent to the treatment plan (if we are following an evidence-based protocol) they will get better faster. We need to spend more time focusing on quality assessment and treatment. I’m debating increasing the amount of one on one treatment time as it will force staff to really dial in to the patients needs. The clinic might earn a bit less in the short term, but I think in the long term the results will speak for themselves.
I found it quite interesting in the Resnik (2008) study that more experienced clinicians did not achieve the best performance. If I’m not mistaken this is in concordance with a study on physicians. Why might this be? Well I think that practitioners can get complacent and not stay on top of the latest research. They also have the barrier of changing their practice style and accepting what they might be doing is not the best use of time. Using several modalities is an example: research does not support its use for the vast majority of conditions, yet professionals has been indoctrinated into it from their school days-when it might have been the new thing on the block. Practice methodology differences highlight how even though someone is a more experienced clinician, their results might be poorer. It’s not to say that patients don’t like the therapist, but they’ll just have to come back to see that therapist more frequently to achieve clinical success. In general I think physical therapists are very smart people but sometimes it is a paradigm shift.. The younger therapists tend to be extremely receptive to research and improving their skill set- sometimes they lack confidence and fluidity with their treatment. We must always realise that our profession is both a science and an art. When they combine confidence and evidence they thrive.
The same study showed how the use of physical therapy assistants leads to lower performance. It makes sense. We lose the ideals of investing in the beginning, eliciting the patients perspective, demonstrating empathy and finally involving a patient in their treatment plan. When patients must see several practitioners in the same visit they have to go through the process a second time. It might work superficially, but it is just a bit disjointed and some important information might get lost in translation.
Overall, I believe that research is the way forward. If we can classify assessment and standardize treatments based on the best evidence we will get the best results. These results can in turn be shared with payers for medical services and physicians to support the prompt use of physical therapy for low back pain. Physical therapy can play an integral part in our health care system. The research clearly shows we can provide cost effective solutions and excellent clinical outcomes. We need to keep building on the research both in our own practice methodology and how we can integrate it into the healthcare system as a whole. The future is bright!
Resnik L, Hart D. Using Clinical Outcomes to Identify Expert Physical Therapists. Physical Therapy 2003; 83:990-1002
Gellhorn AC, Chan L, Martin B, Friedly J. Management Patterns in Acute Low Back Pain :The Role of Physical Therapy. Spine. 2010.
Fritz JM, Cleland J, Brennan GP et al. Physical Therapy for Acute Low Back Pain Associations With Subsequent Healthcare Costs. Spine. 2008. 33:16.
Fritz JM, Childs JS, Wainner RS, Flynn TW. Primary Care Referral of Patients With Low Back P]ain to Physical Therapy. Spine. 2011 37:25.
Fritz JM, Brennan GP, Magel JS, Hunter SJ. Initial Management Decisions After a New Consultation for LowBack Pain: Implications of the Usage of Physical Therapy for Subsequent Health Care Costs and Utilization. Archives of Physical Medicine and Rehabilitation.2013;94:808-16