Several weeks ago, I posted an article entitled, “Don’t be a sugar pill” that received a great deal of feedback. Check back with that article before reading this one if you can to get you updated. I had a case arrive the other day to make me think of this topic even more and made me ponder, am I treating with a standardized treatment approach; or in other words, is what I am prescribing the patient referenced in the literature as the control group?

Image Courtesy: cartoonstock.com

You do not want to be the therapist prescribing control group exercises. Now don’t get me wrong, it works (and studies show from time to time significant improvements in disability, pain, and function with the control group); but is this what we are here for? Shouldn’t we be better and don’t we all want to be considered musculoskeletal specialists and the Go-To clinicians for MSK injuries? We can’t expect to be elite status with standardized treatments.

The first question that may come to mind is, what is the control group? For most studies, it could be no treatment at all, sham treatment (such as putting a patient into a position for MET but not performing it, just getting them to sit in the room for a period of time), or to go with usual care (avoid bed rest, maintain as much activity as possible, use NSAIDs and muscle relaxers). Now I know we do not do these type of control groups but you get what I am trying to come across here. Here are some examples from the literature:

1. Puentedura et al. Development of a Clinical Prediction Rule to Identify Patients with Neck Pain Likely to Benefit from Joint Thrust Manipulation to the Cervical Spine. JOSPT. July 2012. This is a CPR, not a RCT but patients received the below exercise in addition to CSM. So if you are just prescribing this exercise and not performing a manual treatment or a more specific program; you are a control therapist.

Image Courtesy: JOSPT

2. Kachingwe et al. Comparison of Manual Therapy Techniques with Therapeutic Exercise in the Treatment of Shoulder Impingement : A Randomized Control Pilot Clinical Trial. JMMT. 2008. In short, a greater improvement in pain and function was found in the MWM group than exercise group of strengthening parascapular muscles and RTC.

Image Courtesy: JMMT

It was actually much harder to find what I wanted to here while researching the literature (for giving you more examples). There are so many variables out there but I hope you get the point. Be as specific as you can and just don’t go with standardization treatment. Don’t follow your clinic’s “excel sheet of exercises for body parts” or generally flow sheets. This is for extender staff, not clinical doctorate professionals.

If you find yourself giving patients the same treatment (and becoming exhausted with this), then take a step back and ask yourself if you are a control therapist. You are relying on chance association and not causation. If so, just reach in your wallet, take out $25 in cash and give it back to the patient to reimburse them for their co-pay. Then, refer them to google image for exercises so they can find WebMD and do this all from home. You will save yourself, patients and insurance a lot of time and money. 🙂

Advertisements

4 comments

  1. I appreciate this post Dr. V! I have found myself playing it too safe in the past with routine treatments and exercises. It wasn’t until I embraced the concept of risk managment and the meaning of “Doctor of Physical Therapy” that I began reading studies and making decisions for myself and my patients. I have much respect for the solid evidence we have out there, but we are perfectly capable of using our own minds if we know it’s best for the patient!

    1. Tommy,
      Thanks for commenting and the extra dialogue. I agree, we need to go for what is best for the patient. Good seeing you a few weeks ago again. Hope Boston is greeting you with open bars!
      Hv

  2. Being a control therapist might not always be wrong. We have to remember that Louis’s study is a just the beginning step in producing a clinical prediction rule. It needs to go to the next step of validation and then looked at to see if it makes financial benefit along with increased outcomes. We need to be careful to not make a deveration study of a CPR into an actual Level 1 CPR. We can use this deveration study to help in our clinical decision making, but it should not be our clinical decision maker until it has gone through all the steps a CPR should.

    So, yes I agree we need to use our clinical decision making and not just do the canned control treatment found on the excel spread sheet. But we also need to be careful with our clinical decision making and use the entire body of literature to make good decisions and understand limitations of each study as we use those to guide our practice.

    1. Kory,
      Thanks for commenting. You always bring good discussion to the table. I agree, picking the CPR would not be the best choice to make an inference of a control group (I’ll be honest…had a tough time finding the literature that actually had a control group…). A colleague of mine (who is McKenzie based and very well up on the literature as a whole) made a comment to me once that alot of the exercises that the clinic does is simply control group exercises, and not specific. I hope to make a post soon on the literature says about specific exercise too, especially when it comes to LBP and referred pain.

      Thanks again for reading and following! Hv

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s