PhysioDigest - an educational resource for the musculoskeletal rehabilitation community » Decision making

Volcanic Ash Distorts Perspective

David Fitzgerald — Wed, 21 Apr 2010 06:00:21 +0000

The recent volcanic eruption in Iceland and the associated ash plume has devastated air transport in Europe for five days and looks set to continue. Many issues have been exposed including massive price inflation in the hotel, car rental and catering sectors. What has also become apparent is the breakdown in co-ordination of alternative systems like rail, bus, road and ferry transport as people have struggled to find other ways to move around.

This reminded me of a recent conversation on the topic of clinical guidelines of what our expectation are in relation to the guidance they provide. In today’s climate it is hard to escape the reality of evidence based practice and as front line clinicians we are often confronted with the situation of a lack of evidence to justify a particular clinical intervention.

As the saying goes: lack of evidence does not infer lack of effectiveness – it may simply be a reflection that the necessary clinical trials have not been undertaken. I was recently reviewing guidelines on the management of acute low back pain and International best-practised standards. Let’s just review here the core elements that these guidelines make

What we know – Good Evidence…..

Avoiding bed rest

Early activity

Using activity quota’s to guide progression

Reduction of Fear & Anxiety

Advice

What we know – Moderate Evidence…..

Specific stabilisation

Spinal manipulation

McKenzie approach

What we don’t know – No evidence…..

Active Therapy

Muscle Stretching

Postural Training

General strengthening

Specific strengthening

Fitness

Work Hardening

Passive Therapy

Joint manipulation

Massage

Heat

Acupuncture

Electrotherapy

TENS

What struck me most about these best practise guidelines is just how general they are – which by implication means a glaring lack of detail as to what to actually do with a patient in front of us. My academic colleagues tell me that this is the nature what guidelines are supposed to be. My response is that if guidelines are so general and non-specific then do they justify the time, effort and status, which they currently receive?

The danger here is that if generalised guidelines are perceived / recommended as a clinical protocol then it is very easy to conform to principals and not do much with a patient. If current best estimates are that most “simple LBP” is self limiting and will settle in 6 weeks and the estimated recurrence rate is 30% (1 in 3) then how is a policy of rest and NSAID’s then best possible care pathway – even allowing for “slow responders” to be offered supplemental physiotherapy?

This is not a popular assertion but undoubtedly there is a growing industry in reviewing literature, formulating guidelines and castigating clinicians who use treatment techniques that haven’t been scientifically validated. There is a potential conflict here between patient expectations, therapist delivery and 3^rd party payers (state or insurance company).

No doubt all clinicians would love the validity and certainty of knowing that every procedure that they do has been fully researched. I believe the Cochrane Collaboration best estimates of all surgical procedure efficacy is in the order of 15% – not an impressive endorsement but probable not a true reflection I suspect.

Like many things in life we may be striving for a Utopia which doesn’t exist. This then raises the un-mentionable spectre of clinical judgement as part of the decision making process. Before we pay to much reverence to the alter of science I am reminded of the inauguration speech of the current President of the Royal College of Surgeons in which he reminded all faculty members that they must continue to practise the “science and art of medicine” as it had been done through the ages. I thought this was a particularly brave admission in these days where science is king and lack of certainty is derided. If only everything in life was as certain as the scientists would claim wouldn’t things be easy?

Meteorologists tell us the volcanic ash is now clearing thanks to a fortunate change in wind direction. Let’s hope this extends to clinical practise!

Enjoy the clinical challenge

David.

GHTime Code(s): nc 05e8e

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Post tags: acute low back pain, clinical guidelines, clinical reasoning, Clinical trial, Cochrane Collaboration, Decision making, Evidence-based medicine, Health, medicine, NICE guidelines, Physical therapy, physiotherapy, Surgery

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Motor Learning & Performance

David Fitzgerald — Wed, 03 Mar 2010 06:00:51 +0000

Whilst recently reviewing some information on motor learning and performance for a workshop I was giving I was struck by the systematised approach to evaluation which the movement science profession attach to this discipline so today’s post explores some of these oversights. I also think that recognition of these concepts is important to integrate into physiotherapy practice to enhance our treatment outcomes.

The popularisation of muscle imbalance concepts as the fundamental basis for exercise prescription (wrongly in my view) has lead to the popularisation of a particular theory of motor control originally postulated by Posner and Fitts in 1968. This theory outlined three stages of control;

Cognitive phase

Associative phase

Autonomous phase.

The elements of each of these phases have been well described in the literature and have become an excepted paradigm for clinical interventions. However, we must remember as clinicians that this is only one theory of motor control and due to the complex interaction of the many elements involved in motor control, we would do well to consider thoughts of Shumway Cook…

“that motor control theory is a group of abstract ideas about the control of movement which provide the following information;

1) a framework for interpreting behaviour,

2) a guide for clinical action,

3) working hypothesis for examination and intervention and

4) new ideas.”

Profound words indeed.

My recent study on this topic highlighted the following elements:

Motor skill classification:

Motor skills can be classified according to task organisation as:

Discrete skills

Serial skills

Continuous skills.

A discrete skill is one, which is characterised by a defined beginning and end and is often of very brief duration i.e. kicking a ball, throwing an implement.

When a series of discrete skills are grouped together to form a more complicated action these are classified as serial skills suggesting that the order of elements is crucial to successful performance. There may be a number of sub elements that make up the total task in this case. Most activities of daily living fit into this classification.

The final category of skills in this system are those organised in a way that suggest no particular beginning or end, these are known as continuous skills and often repetitive or rhythmic in nature and would include activities such as swimming, cycling, walking and running.

An alternative means of classifying skills is by quantifying the relative importance of motor and cognitive elements. With a motor skill the primary element determining movement success is the quality of the movement itself with less emphasis being given to the perceptual and decision making aspects of the task.

On the other hand, with a cognitive skill the nature of the movement is less important to success than is the decision or strategy about which movement to make. It has been said that a cognitive skill is one that mainly emphasises “knowing what to do”, whereas a motor skill mainly emphasises “doing it correctly” – Of course the big debate here is what constitutes correctness!!.

Classification by environmental predictability:

Another way to classify motor skills is to consider the extent to which the environment is stable and predictable throughout the motor performance. Open skill is one that is performed in an environment that is variable and unpredictable during the action. A closed skill in the other hand is one that is performed in an environment that is stable and predictable. The open/closed skill classification system emphasises the relative demands placed upon the performer to respond to moment-to-moment variations in the environment. For skills at the closed end of the spectrum individuals have the potential to evaluate the environment in advance, organise the movement without significant time pressure and execute the action without the need for sudden adjustments. However, skills which are in the open end of the continuum requires the performer to utilise processes of perception, pattern recognition and decision making to adjust the movement, often in a short amount of time in response to changing environmental conditions.

If we review these three classification systems it is clear that there is overlap and as clinicians we need to consider each system simultaneously when attempting to evaluate a skilled task or the means by which we need to structure our intervention.

I was refreshed at exposure to these concepts and will certainly endeavour to incorporate this framework into my decision making, movement analysis and skills training in the clinic.

Enjoy the clinical challenge.