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Research, Physiotherapy, and Modern Musculoskeletal Medicine
192
Research, Physiotherapy, and Modern Musculoskeletal Medicine
Key Words Discourse analysis, research methods, post-modernism, modernism, back pain. by Nicholas Harland
Discourse analysis
Summary The healthy debate surrounding the treatment of chronic musculoskeletal pain, particularly back pain, and the advantages and disadvantages of current evidence-based practice continues. It is through just such debates over topical issues in health that the practice of medicine evolves. It appears, however, that one perspective remains very much in the background of the debate over the treatment of and research into chronic musculoskeletal pain. This is the perspective of the discourse analyst, or social deconstructionist. The purpose of this paper is to use these theoretical standpoints as a context within which to analyse critically the current nature of musculoskeletal research.
Harland, N (2003). ‘Research, physiotherapy, and modern musculoskeletal medicine: Discourse analysis’, Physiotherapy, 89, 2, 192-197.
Introduction Discourse analysis is usually seen as the prerogative of the social scientist but its direct application to medicine has much to offer. Discourse analysis, or social deconstruction, is simply about taking a step backwards and viewing a philosophy, a profession, a speech, or even a paragraph of text, from a standpoint that attempts to distance itself from the common assumptions we make about the world (Burr, 1995). To a discourse analyst there is no such thing as right or wrong, or even physiotherapy – there are simply popular assumptions, or discourses, that society has constructed, and for the time being, continues to construct. In this way truth is seen as a transient thing that is constructed by society, and is subject to change as society changes (Scambler, 1987; Stevenson and Beech, 1998; Traynor, 1996). This point is easily exemplified through any historical observation. For example, at one time society firmly believed the earth to be the centre of the universe. This was was seen then to represent truth, but now that truth has dramatically changed. Essentially discourse analysis acts as a platform for epistemological debate, epistemology being most simply defined as ‘the study of the nature of knowledge’
Physiotherapy March 2003/vol 89/no 3
(Burr, 1995). Although discourse analysis has an open definition, being interpreted in a different way by every individual, its basis is in the realisation that truth is constructed within the fluid frameworks of society and time, and what may be seen as truth within one discourse may not be so within another. Within medicine, for instance, randomised controlled trials are seen as the highest standard of research method, but within some social science discourses they are seen as inherently flawed because they try to quantify subjective experiences objectively. Throughout history society and truth have been through intense periods of change, such as the transition from medieval to renaissance. Currently society is changing, moving from a modern to a post-modern discourse, but medicine and what it regards as truth are lagging behind that change (Chan and Chan, 2000; Mallinson, 2002). Wider Context Before being specific it is first necessary to place physiotherapy, and medicine, in the context of modernity as a wider cultural discourse. The application of science and reason to virtually every aspect of life, and the creation of such entities as psychology, politics and medicine, defines modernity as it is thought of today (Traynor, 1996). The reason science and modernity have been accepted so completely is that they have brought about perceived benefits to society such as electricity, flight and antibiotics. Recently, however, we have begun to perceive some of the hazards of modern science and therefore question the value of any possible future benefits. The pursuit of modernity has brought about catastrophic developments such as nuclear accidents, virtually indestructible and lethal super viruses, and a hole in the ozone layer. These were not predicted by
Opinion
science, and are not seen as beneficial. This has caused the value of the technology that brought them about to be questioned and has inevitably led to more general questioning of the overall value of modern deterministic scientific endeavour. This has led to what has become known as post-modernism (Chan and Chan, 2000; Philips, 1997) which is essentially a discourse defined by the important concepts of value and choice. This could be said to contradict science and modernism which rely on such concepts as correct and incorrect (Stevenson, 1998). Post-modernist thinking is exemplified in qualitative research such as that by May et al (2000) that explores how patients account for chronic low back pain. Such papers do not result in treatment recommendations and have no quantifiable results, but provide knowledge that facilitates therapist reflection on how constructive communication can be achieved between themselves and patients who have often been the subject of scepticism and have not received any reasonable explanation for their pain. The emphasis of such papers is on understanding patients and although no attempt is made to direct a treatment approach, more effective treatment may still result. Modern Medical Discourse Currently, however, medicine still adheres predominantly to a modern scientific discourse (Chan and Chan, 2000; Stevenson and Beech, 1998), exemplified by quantitative research and evidencebased practice (Smith and Sutton, 1999). This adherence is secondary to the assumption that this type of research is beneficial, and that it benefits patients. When this premise is abandoned along with the issue of whether any research outcome is correct or incorrect, it is possible to start analysing the medical research discourse and judge its effect on its primary stakeholders – the patients. For instance time, expertise and money may produce a research paper that validates a new audit questionnaire to measure pain. However this new tool may take seven minutes to fill in and four minutes to score and as a result it may never be widely used. This research has, therefore, resulted in virtually no benefit for patients and has, by adding
193
another tool to this area, not only made comparison of effectiveness between departments using the tool and other departments using more traditional tools impossible, but has also made the literature search and decision-making process for those searching for a pain measurement tool to introduce to their practice more problematical. Alternatively if similar resources had been directed towards setting-up a series of focus groups to identify patients’ feelings towards pain management programmes in a group of hospitals, constructive changes in these programmes, directly benefiting patients, might have resulted. Research into chronic musculoskeletal pain, particularly back pain, demonstrates the problems inherent in the modern medical discourse. By now it is well documented that the adoption of a unimodal medical model of back pain since the Second World War has, at least partially, caused the drastic rise in disability secondary to this normally benign and self-limiting condition (Gifford, 2000; Waddell, 1998). It is also clear that it was partially a lack of understanding of the patient as a whole that led to this ‘disaster’, as Waddell (1998) puts it. What medicine is in danger of missing, however, is that much modern musculoskeletal research still does not necessarily add to our understanding of the problem, and therefore may not give value to those it is intended to benefit, the patients.
Author and Address for Correspondence Nicholas Harland MSc MCSP is studying for a PhD and is a superintendent physiotherapist in the spinal rehabilitation unit of Friarage Hospital, Northallerton, North Yorkshire DL6 1JG. This article was received on September l7, 2001, and accepted on June 14, 2002.
Induction and Explanation Although it is a difficult concept to understand fully, and is well beyond the boundaries of this commentary to explain fully, ‘the problem of induction’ first formalised by Karl Popper (Deutch, 1997) is also partially the problem with modern research. It basically states that the result of an experiment may show an outcome but this does not guarantee the same outcome in the future, no matter how many times the experiment is repeated, and the same result found (Deutsch, 1997). What is missing from the equation is explanation. Unless an experiment is backed up by understanding and explanation we cannot rely on future outcomes of the same experiment because we do not fully understand why that outcome came about. Physiotherapy March 2003/vol 89/no 3
194
Another perspective on the problem is to look at cause and effect. Much current research is designed to compare the effect of two or more treatments so that the most effective can be preferentially used, but the issue of the cause is often ignored. Essentially treatment modalities are picked to compare through modem research techniques, without prior theoretical debate about why one may be superior. When a result is found it is then difficult to hypothesise why that result was found, as the experiment was not designed to test any pre-formulated theories. For example ultrasound might be compared with deep frictions for tennis elbow and although ultrasound may be found to be more effective it remains unclear why. However it might be hypothesised that frictions produce less heat than ultrasound in the affected tendon and will therefore not be so effective. An experiment to compare the two modalities could, however, be run on the same terms as the first experiment except a device could be used to measure the heat in the tendon during treatment. The result of this experiment has the same result as the first but also shows that ultrasound did produce more heat than frictions and that this may be a reason for its comparative effect. Only by adding an initial theoretical perspective to research and acting to investigate that theory can the result of such research add not only to knowledge, but also to understanding. Knowledge Not Understanding When the problem of induction is applied to musculoskeletal treatment and research it is, unfortunately, easy to see that medicine is still seeking knowledge, rather than understanding. This is demonstrated simply by the volume of quantitative experimental research, examining effect, that dominates the literature. Mallinson (2002) has gone so far as to say, in reference to the area of health measurement research that opitimises the quantitative approach, that such research seems to ‘exalt the method, without genuinely appraising its ability to produce the knowledge required’. One danger of this is that without better understanding it is difficult to predict the long-term results of treatments arising from such research, such as the iatrogenic Physiotherapy March 2003/vol 89/no 3
disability found in many back pain patients. The most obvious example of the problem in musculoskeletal medicine is simple manipulation. Physiotherapy and medicine have built up an industry around manipulation, and society has willingly bought into the discourse. There are theories about its effect, but they do not objectively and measurably explain how it works. Although various theoretical standpoints such as those of Cyriax and Maitland are based around the concept of joint movements producing beneficial pain responses and tissue changes, no single definitive explanation has been reached. Objectively this is demonstrated by the simple existence of so many similar platforms. There is evidence for some of these theories in the form of metaanalyses which indicate that manipulation may be effective for acute back pain (Barton, 2000), although this is not true for chronic back pain (Van Tulder, 2000). This demonstrates knowledge, but does not explain why this treatment succeeds or not, and this demonstrates a lack of understanding. There is no intent of bias here and similar examples can be found throughout musculoskeletal medicine. Essentially when the assumptions that current research practice is unimpeachable and that quantitative research outcomes should guide practice are discarded, it is difficult to see how medicine has progressed from the post-war era, when a lack of understanding of the patient as a whole and a tendency towards deterministic scientific endeavour played its part in adding to the situation found today with chronic back pain. To further demonstrate the point we could analyse a fictitious example of a randomised controlled trial comparing exercise for back pain with massage. It may report that exercise is more successful and this can be perceived to have furthered treatment for these patients. When, however, exercise is dutifully prescribed for a back pain patient and it fails to work, there is no answer to the question of why it failed. Is the patient’s problem simply too severe? Does the patient require psychological input to break free of pain behaviour? Will a different treatment work? Usually, and unscientifically, it is personal clinical judgement that provides the answers to such questions. If, however, more was
Opinion
understood about how and why exercise worked it could perhaps be discovered what was different about the patient that prevented him or her from benefiting from the treatment. It may seem obvious and simplistic to state that all patients are different, and it is those differences that make them react differently to treatments, but adherence to the modern research discourse appears to ignore this fact. Best evidence is usually thought of in terms of meta-analysis and randomised controlled trials. When the assumption that randomised controlled trials are the ‘gold standard’ of medical research is examined however (Greenhalgh, 1997) it can be seen that virtually by definition, randomised controlled trials deny that patients are different. The purpose of randomised controlled trials is, by selecting patients without bias, and then randomly assigning them to groups, to discover if a treatment works for essentially average patients. This leads to the questions: Does Mr Average ever consult a physiotherapist for treatment for back pain? And if he did, would he be recognised? An experiment that examined only working males between 30 and 50 years of age with normal anxiety and depression scores, and who demonstrated no overt pain behaviour or maladaptive coping strategies, would be criticised on methodological grounds and be excluded from meta-analytical studies that guide practice. Yet these patients can be recognised when they consult for treatment, and such an experiment may in fact answer the question of how to treat them. Though some studies do identify groups discovered within samples that acted differently, this tends to be more as an adjunct and is sometimes lost in the eagerness to report in the final conclusion that for Mr Average the treatment does or does not work. Dichotomy Although it is a simplification, in essence the deterministic modern medical discourse defines both success and truth as basically dichotomous variables, when both post-modernism and common sense would argue that it is impossible to answer with a simple yes or no the question: Does this treatment work? (Chan and Chan, 2000, Stevenson and Beech, 1998). Two solutions would at least part-
195
ially address the issues that have been described. The first is to standardise outcome measurements across larger populations of clinicians and to enter these data with detailed sociodemographical information on to an appropriate statistical package. In this way direct comparisons of effectiveness could be obtained between departments and also between clinicians, and the differences in practice between more and less effective groups could be investigated in order to increase effectiveness overall. Certainly what is essentially performance evaluation of this type is threatening but this should not stop practice that leads to better patient care. The second solution is to perform more research that investigates cause as well as effect. Certainly this is a significant challenge, as in the example given earlier of an experiment comparing ultrasound with deep frictions, a way of measuring heat in a tendon would have to be developed and this would perhaps be much more difficult than the resultant research itself. Such steps become necessary, however, when deeper understanding is the long-term goal. Each project of this type would undoubtedly have challenges beyond that of designing the research method itself, initially requiring a possible causal factor to test, and a way of testing it. It also appears likely that co-operation between therapists and a variety of other professionals would be necessary, but the results of such efforts are likely to bring significant rewards. Study of Therapists The other area where deconstruction of the dominant discourse reveals problems with current research practices involves an important confounding variable in every experiment, the therapist. The great importance of such things as placebo, nocebo, and effective communication skills has been recognised for years (Gard et al, 2000; Gifford, 2000; Simmonds, 2000; Waddell, 1998), but how often are research skills directed towards specifically investigating therapists? Although one-to-one personal communication dominates virtually all physiotherapy practice, and affects the outcome of so many clinical actions, it seems strange that courses on effective communication and counselling practices are Physiotherapy March 2003/vol 89/no 3
196
not much more commonly advertised in medical journals, and that articles such as those by Gard et al (2000), Harrison and Williams (2000) and Cook and Hassenkamp (2000) are not next to the latest Cochrane Review on more therapists’ desks. How many research projects examine the psychosocial aspects of a group of different therapists applying the same treatment to a group of patients? This certainly seems a frightening proposition, and as clinicians and individuals we can imagine how we might feel if asked fill out a long and detailed personal questionnaire at the start of a study, and when our ability to communicate is critically evaluated by an expert during treatment. But how different is this from what patients are put through during research projects? Perhaps an insight into our own feelings when we are the subject of experimentation can help us realise how much of an effect emotions have on our own and therefore our patients’ performance, especially under research conditions. Perhaps if we were able to appreciate personally the anxiety a physical examination causes patients, we could examine and research in a more sympathetic way and reduce the unwanted effects anxiety has on patients during examination, and on the conclusion we draw from that examination (Hadjistravropoulos and LaChapelle, 2000). The solution to such issues lies in clinical reflexivity and open-mindedness. It is important for therapists reading and evaluating research to not only ‘exalt the method’ but also to reflect on what knowledge and understanding can actually be gained through the exercise, and then evaluate if this knowledge could, or should, be used to change treat-
ment practice in a way that may benefit patients. It is part of clinical professional responsibility to seek the best treatment available for each patient and to appreciate that this treatment may not be the same as that recommended in a best practice review for the patient’s condition, because patients are much more complex than their diagnosis. It is also necessary to reflect upon the importance of the therapist-patient relationship, and if treatment fails, to look further than the treatment modality for an answer to the question of why that treatment failed. There seems a strong argument that if clinicians were as familiar and practiced in the principles of unconditional positive regard and reflective communication as they are with exercise prescription and mobilisation they would be more effective. Conclusion The purpose of such questioning is not to seek the downfall of the scientific institution, and certainly such arguments are not directly applicable to all areas of medicine, but within the complex discipline of musculoskeletal medicine it seems only prudent to occasionally step back and ask a few difficult questions, such as: Are we occasionally guilty of research for its own sake? When we examine research that compares one treatment with another do we actually understand why treatment A was better than treatment B? Should our next research project examine therapists’ rather than patients’ behaviour? And should the next course we attend be directed at improving our manual skills or our psychological and communication skills?
Key Messages ■ When reading quantitative research think about what the results actually mean and whether they are relevant to the context in which you wish to apply them. ■ Best evidence relates to diagnosis rather than to a person, so evaluate the possible effects of treatment in relation to both of these factors.
Physiotherapy March 2003/vol 89/no 3
■ If treatment is ineffective, determine whether failure is due to the treatment itself or the way in which it is administered.
Opinion
References Barton, S (2000). Evidence: A compendium of the best available evidence for effective health care, issue 4, BMJ Publishing, London. Burr, V (1995). An Introduction to Social Constructionism, Routledge, London. Chan, J J and Chan, J E (2000). ‘Medicine for the Millenium: The challenge of postmodernism’, Medical Journal of Australia, 172, 332-334. Cook, F M and Hassenkamp, A (2000). ‘Active rehabilitation for chronic low back pain: The patient’s perspective’, Physiotherapy, 86, 61-68. Deutsch, D (1997). The Fabric of Reality, Penguin Books, London. Gard, G, Gyllensten, A L, Salford, E and Ekdahl, C (2000). ‘Physical therapists’ emotional expressions in interviews about factors important for interactions with patients’, Physiotherapy, 86, 229-240. Gifford, L (2000). Topical Issues in Pain 2, NOI Press, Falmouth. Greenhalgh, T (1997). How to Read a Paper, BMJ Publishing, London. Hadiistravropoulos, H D and LaChapelle, D L (2000). ‘Extent and nature of anxiety experienced during physical examination of chronic low back pain’, Behavioural Research and Therapy, 38, 13-29. Harrison, K and Williams, S (2000). ‘Exploring the power base in physiotherapy’, British Journal of Therapy and Rehabilitation, 7, 355-361.
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Mallinson, S (2002). ‘Listening to respondents: A qualitative assessment of the Short-Form 36 Health Status Questionnaire’, Social Science and Medicine, 54, 11 -21. May, C R, Rose, M J and Johnson, F W C (2000). ‘Dealing with doubt: How patients account for non-specific chronic low back pain’, Journal of Psychosomatic Research, 49, 223-225. Philips, L (1997). ‘The art of nursing in a “post-modern” context’, Journal of Advanced Nursing, 25, 38-44. Scambler, G (1987). Sociological Theory and Medical Sociology, Tavistock Publications, London. Simmonds, M (2000). ‘Pain and the placebo in physiotherapy: A benevolent lie?’ Physiotherapy, 86, 631-637. Smith, C and Sutton, F (1999). ‘Best practice: What it is and what it is not’, International Journal of Nursing Practice, 5, 100-105. Stevenson, C and Beech, I (1998). ‘Playing the power game for qualitative researchers: The possibility of a post-modern approach’, Journal of Advanced Nursing, 27, 790-797. Traynor, M (1996). ‘Looking at discourse in a literature review of nursing texts’, Journal of Advanced Nursing, 23, 1155-61. Van Tulder, M W, Koes, B W, Malmivaara, A and Esmail, R (2000). ‘Exercise therapy for low back pain’, The Cochrane Library, 2. Waddell, G (1998). The Back Pain Revolution, Churchill Livingstone, London.
Physiotherapy March 2003/vol 89/no 3
Research, Physiotherapy, and Modern Musculoskeletal Medicine
Key Words Discourse analysis, research methods, post-modernism, modernism, back pain. by Nicholas Harland
Discourse analysis
Summary The healthy debate surrounding the treatment of chronic musculoskeletal pain, particularly back pain, and the advantages and disadvantages of current evidence-based practice continues. It is through just such debates over topical issues in health that the practice of medicine evolves. It appears, however, that one perspective remains very much in the background of the debate over the treatment of and research into chronic musculoskeletal pain. This is the perspective of the discourse analyst, or social deconstructionist. The purpose of this paper is to use these theoretical standpoints as a context within which to analyse critically the current nature of musculoskeletal research.
Harland, N (2003). ‘Research, physiotherapy, and modern musculoskeletal medicine: Discourse analysis’, Physiotherapy, 89, 2, 192-197.
Introduction Discourse analysis is usually seen as the prerogative of the social scientist but its direct application to medicine has much to offer. Discourse analysis, or social deconstruction, is simply about taking a step backwards and viewing a philosophy, a profession, a speech, or even a paragraph of text, from a standpoint that attempts to distance itself from the common assumptions we make about the world (Burr, 1995). To a discourse analyst there is no such thing as right or wrong, or even physiotherapy – there are simply popular assumptions, or discourses, that society has constructed, and for the time being, continues to construct. In this way truth is seen as a transient thing that is constructed by society, and is subject to change as society changes (Scambler, 1987; Stevenson and Beech, 1998; Traynor, 1996). This point is easily exemplified through any historical observation. For example, at one time society firmly believed the earth to be the centre of the universe. This was was seen then to represent truth, but now that truth has dramatically changed. Essentially discourse analysis acts as a platform for epistemological debate, epistemology being most simply defined as ‘the study of the nature of knowledge’
Physiotherapy March 2003/vol 89/no 3
(Burr, 1995). Although discourse analysis has an open definition, being interpreted in a different way by every individual, its basis is in the realisation that truth is constructed within the fluid frameworks of society and time, and what may be seen as truth within one discourse may not be so within another. Within medicine, for instance, randomised controlled trials are seen as the highest standard of research method, but within some social science discourses they are seen as inherently flawed because they try to quantify subjective experiences objectively. Throughout history society and truth have been through intense periods of change, such as the transition from medieval to renaissance. Currently society is changing, moving from a modern to a post-modern discourse, but medicine and what it regards as truth are lagging behind that change (Chan and Chan, 2000; Mallinson, 2002). Wider Context Before being specific it is first necessary to place physiotherapy, and medicine, in the context of modernity as a wider cultural discourse. The application of science and reason to virtually every aspect of life, and the creation of such entities as psychology, politics and medicine, defines modernity as it is thought of today (Traynor, 1996). The reason science and modernity have been accepted so completely is that they have brought about perceived benefits to society such as electricity, flight and antibiotics. Recently, however, we have begun to perceive some of the hazards of modern science and therefore question the value of any possible future benefits. The pursuit of modernity has brought about catastrophic developments such as nuclear accidents, virtually indestructible and lethal super viruses, and a hole in the ozone layer. These were not predicted by
Opinion
science, and are not seen as beneficial. This has caused the value of the technology that brought them about to be questioned and has inevitably led to more general questioning of the overall value of modern deterministic scientific endeavour. This has led to what has become known as post-modernism (Chan and Chan, 2000; Philips, 1997) which is essentially a discourse defined by the important concepts of value and choice. This could be said to contradict science and modernism which rely on such concepts as correct and incorrect (Stevenson, 1998). Post-modernist thinking is exemplified in qualitative research such as that by May et al (2000) that explores how patients account for chronic low back pain. Such papers do not result in treatment recommendations and have no quantifiable results, but provide knowledge that facilitates therapist reflection on how constructive communication can be achieved between themselves and patients who have often been the subject of scepticism and have not received any reasonable explanation for their pain. The emphasis of such papers is on understanding patients and although no attempt is made to direct a treatment approach, more effective treatment may still result. Modern Medical Discourse Currently, however, medicine still adheres predominantly to a modern scientific discourse (Chan and Chan, 2000; Stevenson and Beech, 1998), exemplified by quantitative research and evidencebased practice (Smith and Sutton, 1999). This adherence is secondary to the assumption that this type of research is beneficial, and that it benefits patients. When this premise is abandoned along with the issue of whether any research outcome is correct or incorrect, it is possible to start analysing the medical research discourse and judge its effect on its primary stakeholders – the patients. For instance time, expertise and money may produce a research paper that validates a new audit questionnaire to measure pain. However this new tool may take seven minutes to fill in and four minutes to score and as a result it may never be widely used. This research has, therefore, resulted in virtually no benefit for patients and has, by adding
193
another tool to this area, not only made comparison of effectiveness between departments using the tool and other departments using more traditional tools impossible, but has also made the literature search and decision-making process for those searching for a pain measurement tool to introduce to their practice more problematical. Alternatively if similar resources had been directed towards setting-up a series of focus groups to identify patients’ feelings towards pain management programmes in a group of hospitals, constructive changes in these programmes, directly benefiting patients, might have resulted. Research into chronic musculoskeletal pain, particularly back pain, demonstrates the problems inherent in the modern medical discourse. By now it is well documented that the adoption of a unimodal medical model of back pain since the Second World War has, at least partially, caused the drastic rise in disability secondary to this normally benign and self-limiting condition (Gifford, 2000; Waddell, 1998). It is also clear that it was partially a lack of understanding of the patient as a whole that led to this ‘disaster’, as Waddell (1998) puts it. What medicine is in danger of missing, however, is that much modern musculoskeletal research still does not necessarily add to our understanding of the problem, and therefore may not give value to those it is intended to benefit, the patients.
Author and Address for Correspondence Nicholas Harland MSc MCSP is studying for a PhD and is a superintendent physiotherapist in the spinal rehabilitation unit of Friarage Hospital, Northallerton, North Yorkshire DL6 1JG. This article was received on September l7, 2001, and accepted on June 14, 2002.
Induction and Explanation Although it is a difficult concept to understand fully, and is well beyond the boundaries of this commentary to explain fully, ‘the problem of induction’ first formalised by Karl Popper (Deutch, 1997) is also partially the problem with modern research. It basically states that the result of an experiment may show an outcome but this does not guarantee the same outcome in the future, no matter how many times the experiment is repeated, and the same result found (Deutsch, 1997). What is missing from the equation is explanation. Unless an experiment is backed up by understanding and explanation we cannot rely on future outcomes of the same experiment because we do not fully understand why that outcome came about. Physiotherapy March 2003/vol 89/no 3
194
Another perspective on the problem is to look at cause and effect. Much current research is designed to compare the effect of two or more treatments so that the most effective can be preferentially used, but the issue of the cause is often ignored. Essentially treatment modalities are picked to compare through modem research techniques, without prior theoretical debate about why one may be superior. When a result is found it is then difficult to hypothesise why that result was found, as the experiment was not designed to test any pre-formulated theories. For example ultrasound might be compared with deep frictions for tennis elbow and although ultrasound may be found to be more effective it remains unclear why. However it might be hypothesised that frictions produce less heat than ultrasound in the affected tendon and will therefore not be so effective. An experiment to compare the two modalities could, however, be run on the same terms as the first experiment except a device could be used to measure the heat in the tendon during treatment. The result of this experiment has the same result as the first but also shows that ultrasound did produce more heat than frictions and that this may be a reason for its comparative effect. Only by adding an initial theoretical perspective to research and acting to investigate that theory can the result of such research add not only to knowledge, but also to understanding. Knowledge Not Understanding When the problem of induction is applied to musculoskeletal treatment and research it is, unfortunately, easy to see that medicine is still seeking knowledge, rather than understanding. This is demonstrated simply by the volume of quantitative experimental research, examining effect, that dominates the literature. Mallinson (2002) has gone so far as to say, in reference to the area of health measurement research that opitimises the quantitative approach, that such research seems to ‘exalt the method, without genuinely appraising its ability to produce the knowledge required’. One danger of this is that without better understanding it is difficult to predict the long-term results of treatments arising from such research, such as the iatrogenic Physiotherapy March 2003/vol 89/no 3
disability found in many back pain patients. The most obvious example of the problem in musculoskeletal medicine is simple manipulation. Physiotherapy and medicine have built up an industry around manipulation, and society has willingly bought into the discourse. There are theories about its effect, but they do not objectively and measurably explain how it works. Although various theoretical standpoints such as those of Cyriax and Maitland are based around the concept of joint movements producing beneficial pain responses and tissue changes, no single definitive explanation has been reached. Objectively this is demonstrated by the simple existence of so many similar platforms. There is evidence for some of these theories in the form of metaanalyses which indicate that manipulation may be effective for acute back pain (Barton, 2000), although this is not true for chronic back pain (Van Tulder, 2000). This demonstrates knowledge, but does not explain why this treatment succeeds or not, and this demonstrates a lack of understanding. There is no intent of bias here and similar examples can be found throughout musculoskeletal medicine. Essentially when the assumptions that current research practice is unimpeachable and that quantitative research outcomes should guide practice are discarded, it is difficult to see how medicine has progressed from the post-war era, when a lack of understanding of the patient as a whole and a tendency towards deterministic scientific endeavour played its part in adding to the situation found today with chronic back pain. To further demonstrate the point we could analyse a fictitious example of a randomised controlled trial comparing exercise for back pain with massage. It may report that exercise is more successful and this can be perceived to have furthered treatment for these patients. When, however, exercise is dutifully prescribed for a back pain patient and it fails to work, there is no answer to the question of why it failed. Is the patient’s problem simply too severe? Does the patient require psychological input to break free of pain behaviour? Will a different treatment work? Usually, and unscientifically, it is personal clinical judgement that provides the answers to such questions. If, however, more was
Opinion
understood about how and why exercise worked it could perhaps be discovered what was different about the patient that prevented him or her from benefiting from the treatment. It may seem obvious and simplistic to state that all patients are different, and it is those differences that make them react differently to treatments, but adherence to the modern research discourse appears to ignore this fact. Best evidence is usually thought of in terms of meta-analysis and randomised controlled trials. When the assumption that randomised controlled trials are the ‘gold standard’ of medical research is examined however (Greenhalgh, 1997) it can be seen that virtually by definition, randomised controlled trials deny that patients are different. The purpose of randomised controlled trials is, by selecting patients without bias, and then randomly assigning them to groups, to discover if a treatment works for essentially average patients. This leads to the questions: Does Mr Average ever consult a physiotherapist for treatment for back pain? And if he did, would he be recognised? An experiment that examined only working males between 30 and 50 years of age with normal anxiety and depression scores, and who demonstrated no overt pain behaviour or maladaptive coping strategies, would be criticised on methodological grounds and be excluded from meta-analytical studies that guide practice. Yet these patients can be recognised when they consult for treatment, and such an experiment may in fact answer the question of how to treat them. Though some studies do identify groups discovered within samples that acted differently, this tends to be more as an adjunct and is sometimes lost in the eagerness to report in the final conclusion that for Mr Average the treatment does or does not work. Dichotomy Although it is a simplification, in essence the deterministic modern medical discourse defines both success and truth as basically dichotomous variables, when both post-modernism and common sense would argue that it is impossible to answer with a simple yes or no the question: Does this treatment work? (Chan and Chan, 2000, Stevenson and Beech, 1998). Two solutions would at least part-
195
ially address the issues that have been described. The first is to standardise outcome measurements across larger populations of clinicians and to enter these data with detailed sociodemographical information on to an appropriate statistical package. In this way direct comparisons of effectiveness could be obtained between departments and also between clinicians, and the differences in practice between more and less effective groups could be investigated in order to increase effectiveness overall. Certainly what is essentially performance evaluation of this type is threatening but this should not stop practice that leads to better patient care. The second solution is to perform more research that investigates cause as well as effect. Certainly this is a significant challenge, as in the example given earlier of an experiment comparing ultrasound with deep frictions, a way of measuring heat in a tendon would have to be developed and this would perhaps be much more difficult than the resultant research itself. Such steps become necessary, however, when deeper understanding is the long-term goal. Each project of this type would undoubtedly have challenges beyond that of designing the research method itself, initially requiring a possible causal factor to test, and a way of testing it. It also appears likely that co-operation between therapists and a variety of other professionals would be necessary, but the results of such efforts are likely to bring significant rewards. Study of Therapists The other area where deconstruction of the dominant discourse reveals problems with current research practices involves an important confounding variable in every experiment, the therapist. The great importance of such things as placebo, nocebo, and effective communication skills has been recognised for years (Gard et al, 2000; Gifford, 2000; Simmonds, 2000; Waddell, 1998), but how often are research skills directed towards specifically investigating therapists? Although one-to-one personal communication dominates virtually all physiotherapy practice, and affects the outcome of so many clinical actions, it seems strange that courses on effective communication and counselling practices are Physiotherapy March 2003/vol 89/no 3
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not much more commonly advertised in medical journals, and that articles such as those by Gard et al (2000), Harrison and Williams (2000) and Cook and Hassenkamp (2000) are not next to the latest Cochrane Review on more therapists’ desks. How many research projects examine the psychosocial aspects of a group of different therapists applying the same treatment to a group of patients? This certainly seems a frightening proposition, and as clinicians and individuals we can imagine how we might feel if asked fill out a long and detailed personal questionnaire at the start of a study, and when our ability to communicate is critically evaluated by an expert during treatment. But how different is this from what patients are put through during research projects? Perhaps an insight into our own feelings when we are the subject of experimentation can help us realise how much of an effect emotions have on our own and therefore our patients’ performance, especially under research conditions. Perhaps if we were able to appreciate personally the anxiety a physical examination causes patients, we could examine and research in a more sympathetic way and reduce the unwanted effects anxiety has on patients during examination, and on the conclusion we draw from that examination (Hadjistravropoulos and LaChapelle, 2000). The solution to such issues lies in clinical reflexivity and open-mindedness. It is important for therapists reading and evaluating research to not only ‘exalt the method’ but also to reflect on what knowledge and understanding can actually be gained through the exercise, and then evaluate if this knowledge could, or should, be used to change treat-
ment practice in a way that may benefit patients. It is part of clinical professional responsibility to seek the best treatment available for each patient and to appreciate that this treatment may not be the same as that recommended in a best practice review for the patient’s condition, because patients are much more complex than their diagnosis. It is also necessary to reflect upon the importance of the therapist-patient relationship, and if treatment fails, to look further than the treatment modality for an answer to the question of why that treatment failed. There seems a strong argument that if clinicians were as familiar and practiced in the principles of unconditional positive regard and reflective communication as they are with exercise prescription and mobilisation they would be more effective. Conclusion The purpose of such questioning is not to seek the downfall of the scientific institution, and certainly such arguments are not directly applicable to all areas of medicine, but within the complex discipline of musculoskeletal medicine it seems only prudent to occasionally step back and ask a few difficult questions, such as: Are we occasionally guilty of research for its own sake? When we examine research that compares one treatment with another do we actually understand why treatment A was better than treatment B? Should our next research project examine therapists’ rather than patients’ behaviour? And should the next course we attend be directed at improving our manual skills or our psychological and communication skills?
Key Messages ■ When reading quantitative research think about what the results actually mean and whether they are relevant to the context in which you wish to apply them. ■ Best evidence relates to diagnosis rather than to a person, so evaluate the possible effects of treatment in relation to both of these factors.
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■ If treatment is ineffective, determine whether failure is due to the treatment itself or the way in which it is administered.
Opinion
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