Letters to the Editor.

Visionary Leadership

To the Editor:

I read your Editor's Note in the November 1999 issue of the Journal. I also read the speeches by Suzanne Campbell and Jan Richardson. A common thread appears to run through all 3 articles. That thread is the need for radical change and improvement in the research into physical therapy clinical procedures.

I agree with your premise that the "educational" programs should be shunned if they are not backed by research or strong statistical data validating the procedure and its purported outcomes. Could not a committee, under the auspices of the American Physical Therapy Association (APTA), be developed to review programs and rate them on a scale from a full recommendation to rejection? At the same time, physical therapists should be educated to look for this recommendation before signing up for these programs. This would constitute a "cultural change" for the physical therapists of today. In addition, the Foundation for Physical Therapy could help fund research into the clinical programs that appear promising to the APTA review process but that do not have sufficient data to get a lull APTA recommendation.

I retired from physical therapy in December 1998 after 21-1 years in the clinic and 7 years in physical therapy management. This gives me the ability to step back and assess the physical therapy practice of today with both an insider's and an outsider's perspective. It is my concern and worry that unless there are changes in the direction of physical therapy practice today, physical therapy will be relegated to play a very small role in the delivery of health care in the 21st century. If physical therapists cannot demonstrate that for every dollar spent for physical therapy services there is a concomitant financial savings in productivity that is greater than the cost of physical therapy services, then I do not think physical therapy can or will flourish in the future.

Do I think that physical therapy can demonstrate financially that the profession can deliver economically viable results? Possibly, in certain areas of physical therapy practice, but not in all areas. However, nothing will be accomplished unless there is strong and decisive leadership at the national level backed up by grassroots support in the field. It is the time for visionary leadership!

Alan F Caniglia PT Snowmass Village, Colo [e-mail]

Functional Capacity Evaluation

To the Editor:

The functional capacity evaluation (FCE) has become an important part of what physical therapists and occupational therapists can add to the rehabilitation process of the injured worker with chronic pain.[1-3] Unfortunately, operationally, when these evaluations are performed, there is great confusion about the kind of information they give and how this information can be utilized.[1] The reasons for this statement and the status of this issue are presented below:

1) Currently, there is not a universally accepted operational definition for functional capacity.[1] Thus, there are numerous measurement approaches[1,3] for functional capacity, each claiming to measure patient fitness for return to work.[3] This situation has created confusion in the field and has masked the central scientific issue of whether these FCEs actually measure the ability of a patient with chronic pain to do a specific job.

2) Although some researchers are using tests normalized for age, sex, and body weight, norms for most FCEs are not yet available.[1] Therefore, it is unclear what these results mean in relationship to "normal" populations.

3) Each job or job category has what has been termed the "demand minimum functional capacity" for that job.[4] Although one may accurately delineate the functional capacity of a patient with chronic pain, that functional capacity may not readily translate into the "demand minimum functional capacity" of the patient's job.[1]

4) Although functional capacity testing usually includes nonspecific tests that do not readily translate into job functions, these tests may not accurately reflect the actual demands of repetitive job activities.[1,5] Thus, job-specific functional capacity batteries need to be developed.

5) Even if one were able to accurately measure the ability of a patient with chronic pain to perform the "demand minimum functional capacity of some job or jobs,"[4] these measurements would not necessarily translate into knowledge of the patient's ability to perform those job functions over an 8-hour period.[1,5]

6) As pointed out by King et al,[3] the validity for predicting actual return to work (predictive validity) for all functional capacity batteries is unknown. Lechner et al[2] have reported on the validity of the Physical Work Performance Evaluation battery, but the type of validity measured was not predictive validity for actual return to work.

7) In an attempt to address some of these problems with functional capacity testing, Fishbain et al[6] developed a functional capacity battery based on the Dictionary of Occupational Titles (DOT). The advantage of this battery was that it partially circumvented the "demand minimum capacity functional capacity" problem. Although the DOT functional capacity battery was found to yield reliable measurements,[6] predictive validity was not tested. In a recent study, the first of its kind, Fishbain et al[7] tested this battery for predictive validity for actual return to work in patients with chronic pain. They found that the DOT functional capacity battery could not predict employment levels. However, if a patient with chronic pain could pass 8 DOT job factor measures (stooping, climbing, balancing, crouching, feeling shapes, handling left and right, lifting, carrying) and had a pain level of less than the 5.4 cutoff point, he or she would have a 75% chance of being employed at 30 months after treatment in a pain facility.

It is important to note that Fishbain et al[7] could not predict actual return to work without taking pain into account. This finding points to the importance of measuring pain in patients with chronic pain and utilizing that measurement to make statements about possibilities for job function. Finally, although this study demonstrated that some DOT job factors have predictive validity in the "real world," it nevertheless again points to the limitations of functional capacity testing for predicting whether the patient with chronic pain will or will not be able to function at some job. Practitioners for functional capacity testing should be aware of these issues in interpreting functional capacity data for patients with chronic pain in the reference to return to work.

David A Fishbain, MD, FAPA Professor, Psychiatry & Neurological Surgery & Anesthesiology University of Miami School of Medicine University of Miami Comprehensive Pain and Rehabilitation Center

References

[1] Abdel-Moty E, Fishbain DA, Khalil TM, et al. Functional capacity and residual functional capacity and their utility in measuring work capacity. Clin J Pain. 1993;9:168-173.

[2] Lechner DE, Jackson JR, Roth DL, Straaton KV. Reliability and validity of a newly developed test of physical work performance. J Occup Med. 1994;36:997-1004.

[3] King PM, Tuckwell N, Barrett TE. A critical review of functional capacity evaluations. Phys Ther. 1998;78:852-866.

[4] Battista ME. Disability evaluations: expectations of insurers and payors. Journal of Disability. 1990; 1:168-177.

[5] Rodgers SH. Job evaluation in worker fitness determination. Occup Med. 1988;3:219-239.

[6] Fishbain DA, Abdel-Moty E, Cutler R, et al. Measuring residual functional capacity in chronic low back pain patients based on the Dictionary of Occupational Titles. Spine. 1994; 19: 872-880.

[7] Fishbain DA, Cutler R, Rosomoff HL, et al. Validity of the Dictionary of Occupational Titles residual functional capacity battery. Clin J Pain. 1999;15:102-110.

What Evidence?

To the Editor:

What evidence do we have for anything we do in physical therapy? After reading your most recent Editor's Note (November 1999), I am not sure I understand what kind of evidence you require. Strain-counterstrain is based, in theory, on influencing the muscle spindle and shutting down the gamma gain. Is this evidence or proof of efficacy of treatment? Is it sufficient to know that the stretch reflex exists, and that in applying a treatment based on quieting this reflex, the measurable and reproducible effect of sustained, often permanent muscle relaxation is achieved? Neurological physical therapy is not my specialization, so I ask the honest question: "What proof do we have that proprioceptive neuromuscular facilitation works?"

If those "who really care about our profession" are distilled down to those who can back up by research findings everything they use in treatment or teach to others, where does that leave the patients I saw today who have been seen by other practitioners, some of whom were physical therapists, and who are progressing under my care? My questions are sincere and not meant to be antagonistic, but it is easy for Immelmann to be a purist in his ivory tower. Perhaps he needs to get his hands dirty a little more often and experience the bump and grind of dealing with real patients in the real world where research is respected but not sanctified.

I am from the high school class of '65 and the physical therapy class of '70, and I have almost 30 years of experience of bumping and grinding daily. My education spans Stanley Paris to Upledger to McKenzie, Maitland, Wyke, Jones.... I must say that in all those years no one has ever accused me of not caring about the profession or not being ethical or moral just because I don't have research to back up all or most of what I do.

I'm out here, and I do care about my profession and the furthering of education that can help patients with their musculoskeletal dysfunctions. I look forward to your answers to my questions and perhaps to you asking me a few.

Doug Longmont, Colo

Editor's Response:

Your letter raises some interesting questions. First, let's us clarify what is generally meant by evidence by those who argue for "evidence-based practice."[1,2] Your first example is, as you state, a situation where, at best, we have an argument that a treatment makes sense, that is, a case for "biological plausibility." This is not evidence of effectiveness or efficacy, and it proves nothing other than that the treatment is derived from an idea--an idea that some people find reasonable and others do not. You ask whether it would be sufficient to say, based on the theoretical argument, that because relaxation is achieved, the treatment has value. I say no.

First, we need to measure the result of treatment and not assume that because we believe something should happen, it does. In addition, we must ask whether we achieved a clinical benefit. That is, have we changed something of meaning to the patient? Have we improved function? Helping our patients is why we exist; therefore, when our patients improve, we should be proud and satisfied. Even when we have a clinical success, however, that does not necessarily mean that our treatment "worked." Some conditions are self-limiting or self-resolving, many other events are taking place in the patient's environment. Without a controlled environment, we cannot isolate the effect of our treatments to show efficacy and effectiveness. This is why we need our researchers to investigate the effects of our clinical procedures, preferably, but not exclusively, through clinical trials. Practitioners should continue to use what the literature has to offer and, most importantly, to use their clinical judgment in the selection and application of interventions, especially those for which we have few data (evidence to support the use or rejection of treatments).

You also mentioned justifying the treatment because there was "a measurable and reproducible effect." I believe the only justification of such a claim would be evidence (you stated it was measurable and reproducible), but you did not supply a reference. I contend that your argument would be better served by your letting me know on what basis the claim is made. Please note that I am not necessarily taking issue with your conclusion. I am asking for evidence so that I can evaluate your claim, rather than blindly accepting it. If we respect the need for evidence and dialogue, such evaluation becomes natural.

Within your letter you credit me with remarks that I never made, particularly remarks about what practitioners should be doing and how they should be judged. For example, the thrust of my note dealt with the responsibility of those who teach continuing education or who otherwise promote methods to others. I believe that these individuals, like the manufacturers and distributors of products, need to examine whether what they are selling works. Similarly, I made the case that, before therapists spend time going to new courses, they should examine the literature for evidence-positive and negative--for the procedures they already use. Nowhere did I state that all treatments should be backed up by evidence before they can be used.

Proponents of evidence-based practice are not saying that practitioners can use treatments only when there is evidence or that they must seek dogmatic adherence to practices because of data. We are saying that clinicians have a moral responsibility to know about the evidence relating to their interventions and techniques and to consider this evidence in patient management. The ethical and moral issues arise not over whether there is evidence for all that we do, but whether we are aware of evidence relating to our actions and whether we choose to base our approaches on our own personal biases when sufficient data exist to suggest we should use a different approach. Physical therapists, like most health care professionals, live in a world of uncertainty for most of our treatments and measurements. That is why so many of us are crying out for additional clinically relevant research. The real world is a place where we can either blindly accept the words of others or appreciate that evidence does exist and should be known. More often than not, we find ourselves functioning without evidence, and as long as we are honest with ourselves anti others and take personal responsibility for our clinical choices, we will be meeting the highest moral and ethical standards. The more we need to function without evidence, the greater will be our uncertainty and, unfortunately, the greater will be the variability among therapists.

You list a lot of people who teach courses as evidence of your search for new ways of managing patients. Did those people have evidence? Had they published about the efficacy and effectiveness of the treatments they were promoting? Did Dr Upledger discuss the literature that clearly indicates that craniosacral rhythms cannot be reliably determined (if, of course, they exist at all)[3] Did the instructor of the McKenzie course discuss the research findings that indicate the McKenzie classification system does not lead to reliable measurements[4] or that the use of the McKenzie system at best seems to have only a small benefit?[5] You asked whether there is evidence for anything we do. The answer is yes! (See box.) There is a growing need for practitioners to understand how to easily obtain evidence, judge it, and apply it for the benefit of their patients.

Is There Evidence? Yes!

Too often, people believe that evidence does not exist. The following references are just the tip of the iceberg and are meant only to be illustrative of what we can find when we look.

Vroomen PC, de Krom MC, Wilmink JT, et al. Lack of effectiveness of bed rest for sciatica. N Engl J Med. 1999;340:418-423.

Holmich P, Uhrskou P, Ulnits L, et al. Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: randomised trial. Lancet. 1999; 353:439-443.

Bo K, Talseth T, Holme I. Single blind, randomised controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women. BMJ. 1999;318:487-493.

Schenkman M, Cutson TM, Kuchibhatla M, et al. Exercise to improve spinal flexibility and function for people with Parkinson's disease: a randomized, controlled trial. J Am Geriatr Soc. 1998;46:1207-1216.

van der Windt DA, Koes BW, Deville W, et al. Effectiveness of corticosteroid injections versus physiotherapy for treatment of painful stiff shoulder in primary care: randomised trial. BMJ. 1998;317:1292-1296.

Walker ME Gladman JR, Lincoln NB, et al. Occupational therapy for stroke patients not admitted to hospital: a randomised controlled trial. Lancet. 1999;354:278-280.

van Baar ME, Assendelft WJ, Dekker J, et al. Effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a systematic review of randomized clinical trials. Arthritis Rheum. 1999;42:1361-1369.

--Jules Rothstein

Jules M Rothstein, PT, PhD, FAPTA Editor

References

[1] Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM. New York, NY: Churchill Livingstone Inc; 1997.

[2] Sackett DL, Rosenberg WM, Gray JA, et al. Evidence based medicine: what it is and what it isn't [editorial]. BMJ. 1996;312:71-72.

[3] Rogers JS, Witt PL, Gross MT, et al. Simultaneous palpation of the craniosacral rate at the head and feet: intrarater and interrater reliability and rate comparisons. Phys Ther. 1998;78:1175-1185.

[4] Riddle DL, Rothstein JM. Intertester reliability of McKenzie's classifications of the syndrome types present in patients with low back pain. Spine. 1993;18:1333-1344.

[5] Cherkin DC, Deyo RA, Battie M, et al. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med. 1998;339:1021-1029.

Benefits of Exercise Therapy

To the Editor: We were interested to read in the report by Clapp et al (August 1999) that 30 minutes of intermittent walking did not exacerbate symptoms or cause any abnormal physiological response to exercise in subjects with chronic fatigue syndrome (CFS). Clapp and colleagues go on to suggest that "some individuals with CFS may be able to use low-level, intermittent exercise without exacerbating their symptoms." They also write that "there are no data suggesting that exercises are effective as a primary treatment for patients with CFS."

These authors do not go far enough in their recommendation and are quite wrong in their assumption regarding exercise as a primary treatment. Our group has published a randomized controlled trial showing that graded aerobic exercise therapy, properly supervised, is a significantly more effective treatment than the same amount of therapist input using only stretching and relaxation exercises.[1] This study showed that 52% of patients rated themselves as "much" or "very much" better alter 3 months of treatment, analyzed by intention to treat, compared with 27% of those treated with a control treatment. At the 1-year follow-up, the proportion of those who rated themselves as "much" better increased to 63% by intention-to-treat analysis (74% by completed patients' analysis). Only 1 patient out of 33 patients rated himself "worse" after treatment, the same proportion as in the control treatment. Four patients dropped out of exercise therapy, and 3 patients dropped out of the control treatment. We excluded patients with a comorbid psychiatric disorder. We concluded that "these findings support the use of appropriate prescribed graded aerobic exercise in the management of patients with chronic fatigue syndrome."[1]

A further study, without any patients excluded on the basis of comorbid psychiatric disorder, has also been published. Wearden and colleagues" reported less impressive results with graded exercise therapy, primarily due to one third of the patients dropping out before the end of therapy. Even so, those who completed exercise therapy made significant improvement in fatigue and aerobic work capacity 6 months after starting treatment. The amount of supervised graded exercise therapy was less than in our own study, and the way the exercise was graded was different as well.

We have gone on to publish a description of how to deliver a graded exercise therapy program to patients with CFS.[3] We suggest that graded exercise therapy is a beneficial treatment for the majority of patients with CFS, particularly in those who do not have a comorbid psychiatric disorder. Continuous exercise seems helpful, provided patients start at a short duration of exercise appropriate to their baseline ability.

Dr Peter White Senior Lecturer and Honorary Consultant Queen Mary and Westfield College University of London 

Kathy Fulcher National Sports Medicine Institute St Bartholomew's London

References

[1] Fulcher KY, White PD. Randomised control led trial of graded exercise in patients with the chronic fatigue syndrome. BMJ. 1997;314:1647-1652.

[2] Wearden AJ, Morriss RK, Mullis SR, et al. Randomised, double-blind, placebo-controlled treatment trial of fluoxetine and graded exercise for chronic fatigue syndrome. Br J Psychiatry. 1998; 172:485-490.

[3] Fulcher KY, White PD. Chronic fatigue syndrome: a description of graded exercise treatment. Physiotherapy. 1998;84:223-226.

Letters to the Editor

Letters to the Editor provide a forum for discussion of all matters that are important to the physical therapy profession. Letters responding to articles should be received on a timely basis to ensure meaningful dialogue. Due to space constraints, we ask that letters be less than 600 words. All letters should be signed.

Receipt of Letters to the Editor is not acknowledged; however, correspondents will be notified if the letter has been accepted for publication. The Journal reserves the right to copyedit letters. Unless extensive copyediting is required, correspondents will not be sent a copy of the edited version to review. Letters regarding a specific article will be printed with an author response whenever possible.

Submission by mail or fax: Letters should be typed, double-spaced. Send two copies to the Editor, Physical Therapy, American Physical Therapy Association, 1111 North Fairfax Street, Alexandria, VA 22314-1488; fax, 703/706-3169. Submission via e-mail: Letters should include the correspondent's mailing address. Send to [e-mail].