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Patient vs. Population Based Medicine Question #1

Discussion in 'Biomechanics, Sports and Foot orthoses' started by drsha, May 5, 2012.

  1. drsha

    drsha Banned

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    From day one on The Arena, I have stated that I am primarily a physician and clinician and not a research scientist or Ph.D.

    Frankly, I find the biased skew for a call to produce EBM that has risen to importance in biomechanics recently, may be calling for the elimination or vestigialization of the physician and practitioner, the expert and the textbook.

    This fact is wearing when applied to biomechanics when weighted upon the fact that so little true, valid, high level evidecne actually exists.
    This very facts calls upon expert opinion to be of great import as we call it {"low level").

    1. Waiting for the evidence to exist before treating a patient in front of a practitioner seems very ludicous from the patient perspective.
    2. The opinions of too many biomechanicsts vascilate from totally evidence based all the way to virtually eliminating evidence as a criteria when somewhere in the middle IMHO should be the current position of us all.

    This means that the very expert nature of our opinions, clinical experience, anecdotal evidence and textbook and theoretical publishing vascilates from being extremely important to worthless from post to post since none of us has evidence to back up our biomechanical protocols.

    If Shavelson, Kirby, Glaser and Payne all have mostly low level, scant additions to the literature to back up our expert opinions and if evidence reigns supreme, why should either the student or the guru listen to anything any of us has to say?

    Here is a quote attributable to one of the following:
    Shavelson, Kirby, Glaser, Payne.

    EBM Question 1 is a two parter.

    Which of these biomechanical experts penned it?


    What do you think of its import and applicability on a Biomechanics EBP or in fact in Modern Biomechanics Doctrines?


    "While I am all for research evidence to support what I do for my patients on a daily basis, I am not supportive of restricting logical and mechanically based treatments that are clinically effective but lacking research evidence, all for the cause of evidence based medicine (EBM). I really think restricting treatments to only those that have research behind them is not always in the patient's best interests.

    I believe that it is only the very near-sighted clinician or the insurance company or the government health plan that is interested in limiting the treatment of individuals with musculoskeletal pain to those treatments that have research evidence behind them. One of the reasons evidence-based research is so popular now is probably that this is one way for insurers and government health to have what they consider a valid excuse to deny effective (what they call experimental ) treatments so that they can save money on health care for the members they are supposedly caring for. I really hope that no one actually believes that these insurers or government agencies care that their decisions to restrict care to only "evidence based treatments" is based solely on wanting to help patients?? Come on now, let's not be so naive!

    For example, since there is no research evidence that the medial heel skive technique is effective at treating patients with posterior tibial dysfunction, then this "experimental" technique, that is now 15 years old, would not have been used by the "evidence based only clinician". I think that the hundreds of patients I have cured from PT tendon pain with this technique are very happy that I didn't wait years for definitive research to finally claim that the medial heel skive orthoses is effective to treat patients with this pathology. I am sure that these patients are very happy that I have used mechanical intuition and modelling techniques to come up with mechanical therapies for many foot and lower extremity pathologies that have not been studied or even had clinical names applied to them. Do you really think that patients care if their treatment is "evidence based" as long as it gets them better and relieves their pain?!!

    I didn't get into this profession to practice evidence based medicine. I got into this profession to make patients better and whatever it takes to make them better is exactly what I will give to my patients, regardless of whether it has research evidence to back it up, or not. I will probably be retired or dead before the research catches up to the many techniques that I use on a daily basis to heal patients' foot and lower extremity injuries. I am not willing to allow my patients to suffer needlessly waiting for researchers to catch up with the logical mechanical thought processes that go into the treatment decisions that I make on a daily basis. I really could care less if someone thinks that I am an "evidence based clinician". However, I do care greatly that patients think that I am an "effective clinician".
  2. Craig Payne

    Craig Payne Moderator

    I will get back to you in a month or so..... I writing too book chapters at the moment and will post extracts:
    Where does knowledge for clinical practice come from?
    What to do in the absence of evidence?

    For What to do in the absence of evidence? it all based around:
    1. Theoretical coherence
    2. Biological Plausibility
    3. Consistency with what evidence there is
  3. efuller

    efuller MVP

    Dennis, my criticism of your work is not because you lack evidence, it's because you provide no logical reason for it working.

    In tissue stress we assume that posterior tibial dysfunction is caused by high pronation moments from the ground. When you treat that by reducing the pronation moment from the ground it should get better. Tissue stress provides a logical choice for your treatment variables.

    Typing the foot, without explaining why the various foot types would function differently, or require different treatments lacks coherence.

    Students should only listen to us when we can clearly explain why we do what we do.

  4. drsha

    drsha Banned

    Well it didn't take long. Where's the "NO Thanks" button when we need it?

    I made no mention of my work and you bring it up off thread exactly as you don't want me to bring it up on your threads.

    You must have a red Porsche in your driveway that counters the vulnerability and insecurity that exists in your mind.

    I could retaliate under our agreed cease fire but I will not. I am secure in my positions and in my work.

    When you say "In tissue stress we assume that posterior tibial dysfunction is caused by high pronation moments from the ground.
    ASS-U-ME makes an ASS of U and Me
    definiton: to take for granted!

    Christianity assumes a virgin birth, Judaism an endlessly burning bush and the red sea parting.
    And Tissue Stress?

    1. I assume that posterior tibial inhibition and exhaustion in addition to the compensatory weakness within the plantar fascia and friends that form the elastic tie beam are inherent, foot type-specific, secondary to the rearfoot and forefoot architectural collapse that has predictably developed and in need of repair.
    In PTTD, that foot type is predictably, most often, the flexible rearfoot, flexible forefoot Functional Foot Type and the treatment is aimed at re-establishing the optimal functional position as best as possible and to strengthen the PT muscle engine and the plantar fascia and friends to re-establish a strong flexible tie beam.

    2. WE, in your statement is Whom?
    IMHO, in America, you are a group united by a "get sick and come to me" biomechanical paradigm that has a small but passionate following.
    Most DPM's have little idea what Tissue Stress is, no less apply its dictums in practice. They don't know what a moment is or its importance until I explain it to them.
    3. YOU (WE) blindly assume all other theories to be incorrect and posture from that position.

    Craig is a professional and responds to my thread civilly and with a non-biased response.

    You Dr Fuller respond with your continued verbal diarrhea attacking me and my work personally when it has nothing to do with the thread.

    Dr Kirby gives you "Thanks" for your comment as if two expert opinions, admittedly low level, will add up to a greater vilification of Foot Centering.

    Instead, he should admit that the quote that I delivered in Question #1 came from these very pages and that it was made by
    Kevin Kirby, D.P.M.

    Please remain on thread when responding to my threads or the editors will be more understanding of my retaliative responses to threads that I have not started.

  5. Wow. 4 posts before the thread degenerated into ad hominems. Is that a record?

    I really don't want to get into this one, but think on this Dennis. Eric's reply was a critique of your work. Your reply was a personal critique of him (his insecurity and vulnerability). On such basis, no thread will be fruitful.
  6. drsha

    drsha Banned

    No, you think on this, Robert:
    Eric, and others, intimated that my threads do not deserve their attention and that instead of reducing its potential fruitfulness, they would simply not participate.
    No one would respond and I would go away. I agreed to do the same.

    If he really believed that, Eric would let my posts live unanswered and the S - - T would float to the surface (think Rothbart Robert).

    His critique of my work, when it had nothing to do with the thread, reveals a personal crusade to reduce its fruitfulness and nothing more.

    Robert, shame on you for eliminating from my post that counters Tissue Stress and that offer assumptions relating to Foot Centering as if they weren't penned.

    Using Craig's brilliant and very important postulates on what we should do in order to evaluate biomechanics in the face of poor and weak evidence (which BTW I have used in my lectures after reading them some time ago) are:
    1. Theoretical coherence
    2. Biological Plausibility
    3. Consistency with what evidence there is

    to that Craig, I would add a 4th:
    4. Clinical success when applied by its advocates (it works)

    Eric's assumption was:
    "In tissue stress we assume that posterior tibial dysfunction is caused by high pronation moments from the ground.

    My assumption was:
    In Foot Centering we "assume that posterior tibial inhibition and exhaustion in addition to the compensatory weakness within the plantar fascia and friends that form the elastic tie beam secondary to the rearfoot and forefoot architectural collapse (from its optimal functional position) are in need of repair.
    (my) treatment is aimed at re-establishing the optimal functional position as best as possible and to strengthen the PT muscle engine and the plantar fascia and friends to re-establish a strong flexible tie beam".

    Is mine that afar from Craig's postulates that it does not deserve some inspection?

    Possibly, one or more of you, including Robert, could critique Foot Centering's assumption for coherence, plausibility and consistency.

  7. Nah. No point when you're in this frame of mind. Its no fun Dennis. Its like arguing with a petulant child. When you're on form you are a stimulating and moderately interesting man with an idea which is worth exploring. However when worzel has his wangling head on, its a lot like an argument with a religious zealot. Only less polite. So I'll pass until you're in a slightly more agreeable frame of mind.

    I will merely say that

    Is not a valid or logical argument because EVERY single weirdo, quack, witch doctor and assorted loonie in the world claims clinical success when applied by its advocate. Every single one. So this criteria does not actually exclude a single modality from trepanning to eating dung to cure halitosis because they all have advocates claiming clinical success.
  8. efuller

    efuller MVP

    The topic implied in the original post was how should a student select a paradigm to make clinical decisions when there is an absence of evidence. One answer was coherence. In my answer, I gave examples of coherence. The quote directly above lacks coherence in that there is no explanation of how foot types predict architectural collapse. There is no criteria for what the optimal foot position is. There is no explanation of how the treatment puts the foot in the optimal foot position.


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