Survivorship Bias and Physical Therapy

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Everyone has hopefully had a “eureka” moment in the clinic— The patient no one was able to help before, who by some stroke of genius (or more likely, luck), you are able to assist in a way that is truly remarkable. These successful outcomes are likely to stick with you. They are salient, positive and downright enjoyable to think of. Our memories of positive outcomes stay with us because most of us want to be successful clinicians. So naturally, it makes sense to try and re-create what we did, or to emulate what others did to succeed. In reality though, this does not work out so well. Continue reading

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Poking Holes in the Evidence for Acupuncture

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Throughout this entire discourse on acupuncture and needling for painful problems, Dunning et al have shown an inability or unwillingness to address central points in our argument against the effectiveness of acupuncture and needling. In addition to arriving at vastly different conclusions regarding the current trial data, Dunning and colleagues have routinely shifted the focus of the debate and presented arguments that do not relate directly to the primary issue of acupuncture’s benefits. Further, Dunning et al have consistently demonstrated a fundamental misunderstanding regarding the philosophy and implementation of evidence based practice. Their present reply is no different as they commit several critical errors in their conceptualization of evidence based practice.

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Tearing Down the Pillars of Evidence Based Practice

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One of the most common arguments stemming from our recent post on acupuncture, Needle in the Hay, was that we as a profession should not overly rely on “1/3rd of the pillars of evidence based practice”. This argument shows nothing more than a fundamental misunderstanding of what evidence based practice is. The concepts of evidence, clinical experience/expertise and patient values do not exist independently from one another. Nor can we pick and choose which of the three best suits a particular set of beliefs. In fact, we should stop referring to evidence based practice in terms of “pillars” altogether. It is an unhelpful metaphor that only serves to perpetuate a misinterpretation of the philosophy of evidence based practice. Continue reading

Needle in the Hay – A Reply to Dunning et al

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Dunning et al write that the “the purpose of this article is to directly respond to these claims in a public forum”, however after reading their reply it would seem their idea of directly responding to the claims in our article are to craft an argument from authority, attempt to demonstrate proof by verbosity, mischaracterize the points we made and to shift the goal posts away from the actual acupuncture data towards ad hominem attacks on our personal and professional credibility. We see no part of Dunning et al’s reply that adequately addresses the crux of our PT in Motion article — The fact that Dunning et al misrepresented the findings of the Manheimer (2010) and Vickers (2012) systematic reviews, which include many of the trials Dunning et al cite in their original article and their recent blog post. Continue reading

On Parachutes and Evidence

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Smith and Pell’s “Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials” has been shared enough times to bolster an argument against evidence based practice that I am compelled to write a blog post about it. For those unfamiliar, Smith and Pell wrote up a satirical randomized controlled trial where one group jumps from a plane with parachutes and the other group uses a placebo parachute. You can guess what the results might be. The issue with the article is that while comical, it is not actually an effective criticism of evidence based practice and its preference for randomized controlled trials over other forms of evidence (such as observational studies). Continue reading

The Bigger Picture

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In the foreword for Pain: A Textbook for Therapists, Patrick Wall writes

I am convinced that physiotherapy and occupational therapy are sleeping giants [in the treatment of pain].

Wall saw persistent pain and disability as a giant problem that required a giant solution. He could not have been more right. In the United States, pain and disability’s total financial cost ranges between 560 and 635 billion dollars. Despite the public awareness for things like heart disease, cancer, and diabetes, total financial costs for pain and disability nearly exceed all three combined. For context, heart disease costs 309 billion annually, cancer comes in at 243 billion and diabetes is about 188 billion. A large portion of the cost of pain and disability comes in the form of hours and days of work missed as well as the medical costs. As the burden of pain and disability continues to grow, so does the body of literature showcasing our profession’s ability to provide a safe, low cost and effective healthcare provider for those in pain. Continue reading

In Defense of Evidence Based Practice

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Lately it has appeared en vogue to criticize the evidence based practice movement in physical therapy. While it can be argued that there are a lot of things wrong with evidence based practice, many of the prevalent criticisms on social media seem to stem from limitations in understanding of what evidence based practice is rather than actual shortcomings of evidence based practice itself. Continue reading