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Evidence-Based Practice in Medicine Part 2: Know the Source

Recently I’ve been receiving emails from well-meaning friends with links to articles touting this or that “cure” for COVID19.  Unfortunately, these articles are often opinion pieces by bloggers or newsletter writers who want to chime in on rumors or anecdotes they’ve learned about online. When reading these types of articles or evaluating claims that “someone” posted on social media that a friend of a friend forwarded to you, how can you determine if the information presented is legitimate? We’ve all heard about bots and trolls spreading fake news throughout the internet.  What tools do we have to evaluate claims, especially ones that contradict what we may be hearing in the mainstream media? 

Question mark made of pills

In our previous blog post on Evidence-Based Practice in Medicine, we looked at the scientific method and how it helps us to weed out ineffective medical treatments so that we can focus on what works.  We apply the scientific method via research studies, conducted at universities, non-profit foundations, or private companiesThe authors of research studies can present their findings to the public in a variety of ways. Usually, a wellrun study will be submitted to a peer-reviewed research journal and if the methodologiesdata, and conclusions are found to be sound, it may be published. Scholars in the associated scientific field are the experts who must review the research manuscript and decide to publish or send the authors back to the drawing board; hence the term “peer-reviewed.”  

An example of a highly respected peer-reviewed journal in the medical field is The Journal of the American Medical Association (JAMA) which is published 48 times a year by the American Medical Association. Its first issue was published in 1883. Another example is the magazine Science which has been published since 1880. There are many more in a variety of specialty biomedical fields. For example, Physical Therapy Journal was first printed in 1921. Research can also be published in industry journals, consumer magazines, corporate communicationsgovernment publications, and so forth.  

Laptop and hand typing

So, when evaluating “research” we first need to know where the information was published. Was it a personal story told on someone’s blog or social media? Was it a report printed by a private company? Was it published in a popular magazine or corporate newsletter? We can figure this out by looking at the reference cited which indicates where to find the original research paper.  Scientific references follow a specific format that most of us learned in school. PubMed is the most commonly used search engine as it contains over 30 million articles in the biomedical fields. References are often linked so you can click directly to the study and examine it yourself 

Bloggers, talk radio hosts, social media mavens, and others will often cite “research” but don’t actually provide a reference to that research on PubMed, Google or any other search engine.  This is a red flag as it means there is no way to authenticate the claims made. For example, someone could write that “research shows that beet juice improves cardiovascular function” but without a reference that you can look up, how would you know if that’s a factual statement? You can do your own investigation on PubMed or Google Scholar of course. Maybe there is a study on that topic, maybe not. But why wouldn’t the author give you the reference or a link to the study they’re talking about? There could be many reasons but it does make the claim sound suspicious, doesn’t it? 

  Dead End SignNow, let’s say that an author does provide a reference to a research study. You find it on PubMed.  How do you know if it’s a good study? How do you know if there are problems with the study? How do you know if the researchers had a conflict of interest, such as trying to prove a newly manufactured drug is safe in order to beat a competitor to market? Finding the research in a peer-reviewed journal may help avoid faulty and fraudulent research studies, but that doesn’t necessarily mean that the author’s claims are valid.  You may be surprised to learn that some authors will cite a reference that contradicts their claims! They’re counting on the fact that most readers won’t look up the original research or be able to evaluate its findings.  Reader beware! 

But for now, let’s review.  When someone writes “a recent study says…” or “researchers agree…” or similar vague phrases we need to think carefully about what they’re saying and see if we can validate their claims. If no evidence can be found, we may need to dismiss their claims.  So, when evaluating what you read online, start by asking three basic questions:  

  1. Is there published, supporting evidence?
  2. Was it published in a respected, peer-reviewed journal?
  3. Does the study appear free of conflicts of interest?

If you can answer yes to all three questions then your next step would be to look at the type of research study published — be it a case study, randomized control trial, retrospective survey, etc.  Evaluating the evidence presented in different types of research will be the next topic in our EvidenceBased Practice in Medicine series.  

If you’d like to experience the difference evidence-based, hour-long, physical therapy sessions can make resolving your pain or healing from injury, call OrthoSport Hawaii at 808.373.3555 for more information on scheduling a free online or in-person consult.

 

Evidence-Based Practice in Medicine: What Does it Mean? Part 1

 

Stethoscope and data

Prior to the COVID19 outbreak, the average person may have never heard the term “evidence-based” but this term has been utilized in the medical field for decades.  When we say that our clinical practice in physical therapy is evidence-based, we mean that the treatments, techniques, and clinical decisions we make are based on the best research and clinical experience available.  The same applies to MDs prescribing specific drugs and vaccines to combat illness, surgeons choosing specific surgical procedures, dentists applying topical treatments to prevent cavities, nurses wearing special protective gear to prevent infection, and so on.   

So where does the “evidence” come from?  First, let’s consider the alternative. Non-evidence-based medicine might use intuition, tradition, inconsistent anecdotes, personal histories, unsystematic clinical experience, etc. to inform diagnosis and treatment decisions.  Prior to the discovery of the scientific method, these were the tools healers had to work with. If something worked once, perhaps it would work again and over time, they developed a list of “cures” for various ailments. Some legitimately helped, many did not.  Sometimes the cures were worse than the original illness or injury.  For example, during the 1918 Spanish Flu pandemic, aspirin was found to help with feverHowever some patients died from aspirin toxicity when given large doses because we knew so little about that new drug 

We’ve come a long way in medicine since the days of bloodletting, non-antiseptic surgery, and lobotomies. This is because most medical practice today is based on research using the scientific method.  So what is this method? (Adapted from Live Science.) 

The steps of the scientific method go something like this: 

  • Make an observation or observations. 
  • Ask questions about the observations and gather information. 
  • Form a hypothesis — a tentative description of what’s been observed and make predictions based on that hypothesis. 
  • Test the hypothesis and predictions in an experiment that can be reproduced. 
  • Analyze the data and draw conclusions; accept or reject the hypothesis or modify the hypothesis if necessary. 
  • Reproduce the experiment until there are no discrepancies between observations and theory. The reproducibility of published experiments is the foundation of science. No reproducibility – no science and therefore no evidence. 

Some key underpinnings to the scientific method: 

  • The hypothesis must be testable and falsifiable. Falsifiable means that there must be a possible negative answer to the hypothesis. 
  • Research must involve deductive reasoning and inductive reasoning. Deductive reasoning is the process of using true premises to reach a logical true conclusion while inductive reasoning takes the opposite approach. 
  • An experiment should include a dependent variable (which does not change) and an independent variable (which does change). 
  • An experiment should include an experimental group and a control group. The control group is what the experimental group is compared against. 

Here is a visual way to think of the scientific method:

flowchart of scientific method

 

As you can see, the process repeats as we gather more and more data regarding a particular question Additional research helps us to reach conclusions we can apply to activities in the everyday world.  For example, years ago in physical therapy we used to administer ultrasound massage to patients with low back pain. The patients may have felt better after having some warm gel massaged into their low back muscles, but was the treatment affecting the cause of their pain? After many research studies, we now believe that ultrasound likely has no significant effect in the overall cure of low back pain. So nowadays, we rarely apply ultrasound because we have other more effective treatments.  Does that mean that ultrasound never helps? No, but it may not be the best use of our limited time with patients. Deciding whether to use something like ultrasound is part of our clinical reasoning, an important part of our treatment choices; but that’s a topic for another time. 

Through the scientific method, we hope to weed out what doesn’t work, and focus on what does.  We then build on the most effective treatments and as science advances our understanding, we are able to cure illnesses and heal injuries that were untreatable in the past. Whether it’s wiping out smallpox with vaccines or reversing heart disease with changes in diet and exercise, the scientific method helps to improve our health and save our lives.  However, like everything human-made, it’s not perfect. In the next installment of this series, we will look at Levels of Evidence to learn more about why some research studies are flawed or skewed, as well as other ways in which the scientific method fails to fullanswer our questions.  

If you’d like to experience the difference evidence-based, hour-long, physical therapy sessions can make resolving your pain or healing from injury, call OrthoSport Hawaii at 808.373.3555 for more information on scheduling a free online or in-person consult.

A Bit About the Biz – OrthoSport Hawai’i in the MIDWEEK

Treating And Preventing Injuries

MIDWEEK STAFF on March 4, 2020 at 10:54 am
www.midweek.com/treating-preventing-injuries

By THOMAS FASULO OrthoSport Hawai‘i Medical Fitness Director

In 2009, Dr. Michael Turner started OrthoSport Hawaii as an outgrowth of his own passion for leading an active, healthy lifestyle. While Turner’s original intention was to operate strictly as a physical therapy clinic, he began to see a glaring issue in the current medical model. This model does little to stop the revolving door of re-injury and largely ignores the need for prevention.

So, he developed the Medical Fitness Program, combining the best of both worlds — injury treatment, post-injury care and preventative wellness. Kinesiologists, athletic trainers, physical therapy assistants, postural specialists, medical massage therapists, and registered dietitians joined the physical therapy team to create a one-stop-shop for injury prevention and wellness needs.

Working closely alongside each other, we have created medical fitness programs such as a boxing class for Parkinson’s patients; the BrainFit workout, which combines physical and mental training to promote healthy brain function; and many other specialty group fitness classes. These classes, along with one-on-one rehab and training sessions, can make an active, healthy lifestyle an achievable reality for anyone, no matter their age or ability level.

Anne Davis, an Egoscue postural specialist, provides medical fitness training on The Shuttle.
Anne Davis, an Egoscue postural specialist, provides medical fitness training on The Shuttle.

In 2015, we expanded our services to the heart of downtown Honolulu. In addition to our Kaka‘ako location inside Queen’s Island Urgent Care on Keawe Street, we recently opened a 1,600-square-foot clinic on the lobby level of Topa Financial Center at Bishop Street and Ala Moana Boulevard.

Catering to professionals suffering from pain associated with desk work, the avid golf or tennis player, young athletes or simply downtown residents, the downtown and Kaka‘ako clinic teams are prepared to help you remain injury-free and return to the hobbies and activities you enjoy.

Standard medical, auto and workers compensation insurance generally covers physical therapy but may require a doctor’s referral. All other Medical Fitness services are not typically covered by insurance but remain one of the most effective and affordable ways to prevent health issues and maintain wellness.

OrthoSport Hawai‘i can be reached at 373-3555 for any questions or scheduling needs.

The OrthoSport Hawaii Physical Therapy Experience

Our guest author for this post is one of our favorite patients and medical fitness members, WENDY PUNG!  She offers her own experiences and advice for anyone who may benefit from physical therapy and medical fitness to improve their movement, strength, functional mobility, and to decrease or eliminate pain. Thanks Wendy! 

PT – IT’S NOT SO SCARY

By Wendy Pung

So you’ve seen your doctor for that nagging pain or you’ve just had surgery and you’ve been given a prescription for physical therapy (PT). This is your first experience with PT and you have no idea what it is, what to expect, and probably most important of all—am I going to hurt even MORE? Just to let you know, the person who is writing this piece to try to allay your fears about PT is not a physical therapist or any other person working in the medical profession. If OrthoSport Hawaii were an airline, I would be called a “frequent flyer” as I have been sent to PT for nagging pains and post-surgery rehab too many times to count! And these many treatments have nothing to do with anything that the Physical Therapists have done or not done; I just have a lot of physical problems. What is PT anyway?

Woman laughing in aquatic therapy pool

To put it simply, physical therapy is a medical treatment to help decrease your pain and stiffness and improve your motion, strength, and overall functional mobility. The therapists do this using a variety of techniques such as exercises, pool therapy, ice, soft tissue and joint mobilization, to name a few.

You may need a prescription from an MD for PT, it depends on your insurance. You can call OrthoSport Hawaii to find out if you’re not sure. In any case, before arriving at your first appointment, you should find out:  what to wear, whether your medical insurance requires a co-payment for each appointment, what documents you need to bring with you (e.g. a list of medications and hospitalizations, insurance and ID cards, etc.) and the clinic’s cancellation or no-show policy.

When you arrive at your first appointment you will be given a set of forms to fill out and sign. These are no different than the forms that your doctor would give you at a first appointment. The most important form would be the one that asks you to describe the problem that brought you to the clinic to be treated by the therapist. Providing details of your pain, limitations, and the goals you would wish to achieve after PT is completed is crucial at this point so don’t be afraid to lay it all out.

You will then start your appointment with the physical therapist. He or she will start the evaluation by asking questions and assessing your overall condition, by taking measurements and testing your strength, range of motion, flexibility, and balance among other parameters. Remember that if you are having any concerns during this procedure, speak up! I have been treated by MANY therapists and none (so far) has bitten, and all have been very understanding. They are always more than helpful, answering my questions with impressive knowledge of the complexities of the human body and how it works.

Your physical therapist will then devise a plan that is just for you, to get you back to moving and feeling better than when you first arrived, using the techniques mentioned above. If you are given exercises to do in the clinic and “homework,” be sure to do them as directed so that you can achieve the best outcome from the therapy. But if anything that is prescribed gives you more pain or any other new symptoms, be sure to tell the therapist. He or she can then modify your treatment—PT can be hard work sometimes but it shouldn’t make you feel worse so talk to him or her!

Besides the channel of communication between you and your therapist, there is also one between the therapist and your doctor. Your doctor will be sent reports on your progress with PT and if additional treatment is required to get you to your goal, they will coordinate that with your therapist so they’ve got you covered! All you have  to concentrate on is going to your appointments, doing what is being asked of you at the clinic and at home, and you will receive the best outcome from PT! Good luck!

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