Are We Getting Better?
Evidenced-Based, Evidenced-Lead, Evidenced Informed. I have heard countless variations of fellow healthcare practitioners perceptions on research and treatment throughout my 6+ years as a PT. Others completely ignore the evidence, stating that most evidence is 5-10 years behind the curve. The possible reason for this (if it is indeed true) is that any "idea" starts out as just that. A handful of great minds come together, establish a framework and begin to implement that framework. Initially this needs to be tested on a small group of individuals, maybe in a small clinic or lab based setting, then continually expanded on, tweaked, modified, adjusted - you name it. In the mean time however more and more people are receiving "non-evidenced" based care because it makes sense or seems logical, while a different group of researchers simultaneously works to debunk it.
A true evidence based framework is typically derived of 3 very important pieces:
- Clinician Experience
- Patient Expectation
All 3 are crucially important and carry their own weight. For example, 3 different clinicians may read a research article and have 3 completely different perceptions and interpretations of that particular article. While, at the same time, there might be a particular piece of research all 3 seem to agree on, however when presented to "X" patient they do not believe in it, or have had a similar approach used without success in the past. Guess what will happen? No matter how great the technique, method or approach is, and no matter how great you think you are at implementing it, it WILL NOT work for that patient and they will probably seek treatment elsewhere.
On the topic of research, there are up to 3 million research articles published every year according to Josh Cleeland, yet there does not seem to be a correlation to overall reduction in healthcare costs or injury prevention. Case in point alone in North America we are seeing an INCREASE in obesity, heart disease and osteoporosis. In addition 50% of the country is taking some form of prescription medication. 90% of runners continue to be injured or susceptible to injury and our return to sport rate following ACL reconstruction has remained relatively unchanged in 30+ years (~65%).
In a JOSPT viewpoint published in June 2016 there was a noted 18 fold increase in the number of hip labral surgeries from 1999-2009. With recent surveys of orthopedics revealing some alarming findings including the fact that 62% of surgeons did not believe or were unsure if there was an optimal surgical procedure to prevent future arthritis and "many" did not believe there was enough evidence to support the effect of FAI (Femoral Acetabular Impingement) surgery or know of a "best surgical approach". Yet only 25% were willing to to consider a trial or research focusing on surgical versus conservative treatment. These stats are just scratching the surface. Simply ask yourself if you are seeing more patients or less patients then last year. Then ask if your outcomes are better (if you are even measuring them).
The same thing is happening with spinal fusion sugery. Unlike most operations, it actually was tested in four clinical trials, however the conclusion was not what you would hope: Surgery was no better than alternative nonsurgical treatments, like supervised exercise and therapy to help patients deal with their fear of back pain. However, spinal fusion rates continued to soar in the United States until 2012, shortly after Blue Cross of North Carolina, said it would no longer pay and some other insurers followed suit.
Another procedure to add to this list? Meniscal surgery. So what is going on? Is healthcare failing?
We have more professionals then ever board certified, countless gurus, advances in technology and better training programs to go hand in hand with state of the art gyms. Could it be that we are simply overwhelmed with information that we ignore all of it? Or that too many of us are trying to compete rather then progress? We know the importance of moving, eating right and sleeping yet countless people will say they lack all 3 - while seeking answers to their pain and disability in a bottle. Is it that despite the research, there is no way to account for the environmental impacts on our bodies? While reading articles on ground reaction forces and lower extremity pain for instance we can make an assumption about a group of subjects in a lab on a force plate but how does that translate to concrete, asphalt, grass, sand, clay and what is the connection to wearing Nike, Adidas, New Balance, Reeboks, going barefoot or with rain, sun, snow or if the body is fresh, under a state of fatigue or before/during working out. Now let's add other people since your usually not participating in sports alone. The variables become endless and impossible to keep track of.
Now this is not to say that research is not valid or important, it most certainly is, but we have to be careful how we interpret and implement it, and that maybe, just maybe, we should reconsider age old paradigms (i.e. don't flex your spine, don't squat knees over toes/below 90, do your PT 2-3x a week or your homework 1x per day) and challenge the status quo when it comes to movement and rehab/exercise. We need to get back to basics, build joints, improve movement and empower patients.
A PT once told me if you are not changing your treatment approach every 1-3 years, or reflect back and can specifically say "I knew nothing 3 years ago", it is YOU that is falling behind, not the research.