World Confederation of Physical Therapy just held its 4-yearly conference in Amsterdam. ICECReam people were busy trying the spread the word and get early career researchers interested. It was great to speak to lots of different people and a big welcome to those of you tasting the ICECReam for the first time, hope you like it! Here’s a brief overview of some of my impressions, we’d love to hear from you if you agree, disagree or just think what’s below is a steaming pile of crap.
The Good
It was fantastic to see so many different parts of the world represented, it is always a concern that some conferences (and the research world generally) become the domain of a select few, from a select few countries. The WCPT was huge – which obviously has positives and negatives of itself, but a real highlight was getting a small taste of what goes on in lots of different and faraway places. You don’t have to agree or like what you see/hear but getting a fresh perspective is always of value, usually interesting, sometimes amusing and occasionally inspiring.
Another thing that struck me was the sense of enthusiasm. It seemed as though people were really into it, enjoying what was on offer and taking the chance to interact with the presentations, with each other and with everything that is on offer in Amsterdam. Every conference has its moments when the session becomes a running battle to keep the eyelids in the ‘open’ position, the atmosphere here made that fight just a little easier to win.
The Bad
I was a little concerned about how much of the content seemed to revolve around making sure Physiotherapy maintains or increases ‘’its share’’ of the healthcare dollar, at times I wondered a bit if I’d stumbled into a marketing convention. I understand the need for people to run a business but I get worried when it looks like marketing and advertising are dressed up as science. In my view, science is for giving us the best possible answer to an objectively posed question, not for showing something works so people can make money out of it.
This line of thought led me to ask myself another question. I heard repeatedly that RCTs are not the best way to answer questions concerning physiotherapy. Irrespective of whether this is true or not, I really wonder if people would keep asking this question if more RCTs showed that physiotherapy is effective. Is the methodology the problem or is the fact that we don’t like the answer?
The Ugly
I do understand the need for sponsors at events like this and obviously their ‘’support’’ doesn’t come for free. That said, I do wonder about some of the shiny garbage therapeutic equipment in the expo, see my concern above regarding science and marketing. Last but not least – at what point does someone put on a conference and not provide free coffee??? It doesn’t have to be good coffee, researchers expect bad coffee at conferences but making the punters pay for bad coffee is a bit much.
Let us know what you thought.
Steve
14 Comments
Great Post! It was interesting to see the section about clinical practice guidelines. Most of people were really concerned about guidelines, some comments were like: “if CPG state that we need to this, how can we rely upon innovative treatments???” I found this person later selling ultrasound equipments for low back pain!
I agree. But you’ve beaten me to it on the trial denial issue (I was going to have a polite rant on Body in Mind!).
I was in the guidelines session and everytime it was suggested that RCTs are inappropriate for physio, do not detect our obvious brilliance, or more amazingly that we need to “re-examine the evidence based hierarchy” or perhaps “move away from positivism” (!!) there was a ripple of applause around the fairly full and big room. I think you are right to wonder whether the philosophical basis for this is that the trials just didn’t deliver the desired message.
I kind of expect better from some senior academics – it felt much more about advocacy for physiotherapy at times then it did about evidence based practice or science.
But don’t quibble about the trade stands – innovation in placebos is a great thing! I loved the pointy thing with the flashing blue light inm the shape of a target that delivers a “crackcrackcrack” pulse – how could you not feel better!
Great to meet some of you finally! Sorry I missed the beers.
I walked into the convention hall and thought I had somehow fallen into a time warp…never seen so many machines in my life and people in “white coats” looking very sterile and like something out of a sinister James Bond film. Can’t believe you missed an opportunity for beer NoC…should’ve have joined your two well known beer monsters…
Neil
do I feel a BIM blog post comming on? Point’s taken on the “professional feel good /physiotherapy advocacy” trend.
I must confess I find it hard to have much confidence in guidelines that are frequently so generic as to be of limited clinical application.
I’m curious to know as a scientest how you reconcile the known multitude of variables (soft and hard) which influence clinical outcomes with the data obtained in a controlled trail environment?
This may be fundamentally flawed thinking but if the primary clinical focus is on outcome I find myself less concerned about mechanism of effect relative to outcome.
In reality this may mean ill-concieved explanations to patients, inaccurate presentation of the facts, dillusion regarding one’s own personal contribution but in true Machiavellian style I feel “the end justifies the means”.
Is this a signal to retire (a little early!), dillusional “ivory Tower” thinking or just an acceptance of the facts?
My early ( almost) evangelical enthusiasm for understanding mechanisms, pathophysiolgy, and basic sciences is now countered with a compuslory “so what – how does this impact on clinical management and outcomes?”.
Please help…..
PS the increasing commercialisation at physiotherapy conferences is very evident. I don’t have much beef with the snake oil sellers but I do find it irritating for keynote speakers to be peddaling their DVD’s, multi-stage programs, “get the real detail here” type of approach from the podium. Call me old fashioned!
David
Hi David,
Thanks for checking out the ICECReam. I hope you’ll forgive me for replying to a question directed to Neil, and I’ll state up front that I’m not doing so on his behalf!
I think you make a great point about the translation of research findings into clinical practice. Specifically; if studies just keep telling us what not to do, how do you treat the person standing in front of you? To some extent, as a practitioner your concern for the final outcome above all else is fair enough, but it does raise the issue of whether it is OK to knowingly deceive the patient (about the mechanism), even if it is their best interests. The other point I’d make probably applies less to you than perhaps to other clinicians, about, as you put it; “delusion regarding one’s own contribution”. Surely there must be an expectation that a health care professional has an understanding of how their own practice works, even if it sometimes involves just keeping people satisfied while natural recovery takes its course. A quasi-religious belief in some method/technique that is intractable to reasonable criticism can’t possibly be a good thing.
Steve
Love reading your comments everyone! So sorry to have missed WCPT but being an early researcher I’m buried under a PhD and didn’t think it a priority right now.
Re the RCT’s not telling us what we want, sounds a lot like some of the discussions at IASP last year around excluding placebo responders in RCTs! Particularly relevant in my field of Pain in HIV. People with HIV have very high placebo response rates, blame the study design, blame the people, blame the virus – surely its not because the drug is ineffective?!
Hope to meet some of you on a future holiday (I mean conference!)
Hi Romy, thanks for coming on board. I’ve also heard this argument before about placebo interventions being too effective, therefore hiding the ‘real’ treatment effect. It’s completely bizarre but also in my opinion partly a reflection of the state of understanding about placebo effects generally.
I hear a discussion along these lines at the conference last week, it went something like this:
(Physiotherapy) interventions are tested against placebo interventions that include all the same attention, advice, empathetic head-nodding etc etc that is attached to the index intervention, which we label as ‘non-specific’ effects. BUT we all agree the total effect of real practice includes all these non-specific effects, therefore the placebo intervention is effective and obscures the effect of the index treatment.
The counter to this (which wasn’t brought up in that particular seminar because I – and presumably others – wasn’t brave enough) is to propose that, if the above is the case, the intervention only acts via ‘non-specific’ effects. I’m not sure it’s a view that would have got a very sympathetic hearing!
Steve
If a lack of free coffee sounds like a planning flaw, a quote from the ’07 WCPT oral of an Australian ECR –
“[commenting on a common wacky clinical assumption]… now that makes about as much sense as holding a conference without any food.”
Ooops. Great presentation, but didn’t impress the conference organisers for a prize with that one.
I suppose you could add to the counter Steve, if you were feeling brave (I know I wouldn’t have been), that a placebo (control) treatment in a clinical trial is probably a conservative representation of what it aims to control for.
The likely situation is that the known chance of receiving a placebo in a clinical trial may diminish, in part, other ‘non-specific effects’. Arguably this environment improves the chances of showing some sort of true effect of the index treatment, if there is one.
That said I’m not sure that even if guidelines (sorry couldn’t leave out guidelines) were to recommend we disclose in, clinical practice, that “the treatment being provided has been determined like the toss of a coin and there is a 1 in 2 (or 3 etc) chance of receiving no active treatment”, some of us would stop squeezing apples for orange juice.
Chris
[...] was a bit like Bizarro world for me. A colleague of mine, Steven Kamper, has already provided a great post summarizing the conference, but I wanted to build on it a little. So Bizarro world… Usually at conferences, many of the [...]
These trial denial folk are a real liability. The nirvana they dream of, physiotherapy unencumbered by research, existed 2 decades ago and it was not a good place to be. I am old enough to have been there.
We had healthcare funders arguing that they should not fund physiotherapy as there was no evidence that it worked. There was no evidence for much of medicine but allied health was a softer target. The ancestors of today’s trial deniers excelled themselves by alternating between hissy fits and wetting their pants. Their arguments about research being a poor fit for physiotherapy are exactly the same as is being run again today. Those arguments did not convince funders then and I doubt they would now.
We could decide to throw away the 15,500 physiotherapy trials that show that some, but certainly not all, physiotherapy treatments work but it would seem an unwise thing to do. We would be sitting ducks for healthcare funders wishing to save money. I also wonder what would become of physiotherapy if we threw away our existing science-based knowledge to in effect restart physiotherapy in year zero. There have been a few cults that have gone down this path and it usually went pretty poorly.
So my advice to ICECREAMERS is to challenge these people whenever they spout such nonsense at conferences. There is too little serious debate at physiotherapy conferences.
Chris Maher
Steve
I agree with the risks / dangers of “cultism” in clinical practice. As an expert in Outcomes (assuming that was the thrust of your PhD) is part of this conumdrum retated to what is considered a satisfactory outcome and whom is making that call ie Patient, Therapist, or Organisation?
Last time I looked at this in a JOSPT review there was a good discussion on the sometimes conflicting agenda’s of each party – influenced by a myriad of factors.
If we consider a patient focused (not too contentious I hope) strategy then the possible outcomes are either full recovery and return to function, partial recovery with modifications in function or detioration with no prospect of recovery.
This may be a very non-scientific way to describe these clinical realities but accurate I would suggest?.
Perhaps the scientific process should be to identify clearly succesful interventions based on agreed outcomes, and try to extrapolate mechanisms of effect from there?
David
Notwithstanding cringing at the accusation being an ‘expert’ I agree that working out what to measure and how to go about it is certainly a complex undertaking. From a research perspective, I think we are a long way from doing that well, but hopefully better at it than formerly. The question of who’s perspective is a good one, but ulimately one that is best answered at the study design stage i.e. when working out what the research question is. From a clinician’s perspective the issue is less contentious, as you point out; patient-centred outcomes are paramount.
Extrapolating mechanisms from the outcomes of clinical RCTs is certainly one way of trying to get at this information, and I think there can be mileage in this method. I don’t think however it is the only way to skin that particular cat; other designs and experimental work are also likely to give us clues to follow up in the search for the ‘why’ behind lots of clinical conditions.
Steve
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