27 abril, 2008

The Osteopath - "The battle for ideas: a discussion..."

What do other health care professionals without our concepts or tactile skills consider is happening when patients come to them with back pain of no obvious pathological cause?

Usually they don’t know. Even when they have allotted diagnostic labels to some patients, such as torn muscles, sprained ligaments, osteo-arthritic facet joints, and internal disc derangements (for which there is next to no evidence), most are honest enough to admit to being unable to make a diagnosis in the many remaining cases.

Active in the face of pain

Once the lack of a theory on which to base rational treatment was openly recognised in the early eighties, there was a need to fill this conceptual vacuum, but any osteopathic ideas were quite beyond the orthodox pale at that time. So when the concept was proposed that psychosocial factors largely determine the persistence of back pain beyond the acute episode, there being no rival theory in the field, that model became accepted with haste. This also reflected the government’s desperate search for answers to their ballooning bill for back pain disability. To accord with natural history data, a rational application of this model required the cascade of fearful cognition, anxiety, activity avoidance, depression, functional deterioration, unemployment, isolation and loss of confidence to be initiated early in the course of an episode. Rational management was therefore to involve a positive message of maintaining activity in the face of pain from the outset; rest must not be thought of as treatment if this regime was to
succeed. To an osteopath, used often to palpating increasing signs of dysfunction in patients unable or unwilling to unload the paingenerating structures, the practice of encouraging further pain confrontation would seem quite unreasonable and part of management would usually be the appropriate use of temporary activity reduction to initiate recovery. A rational basis for this attitude seemed to be offered in the elucidation by modern neurophysiology of positive feedback effects, by which the wind-up of spinal cord sensitivity through ongoing pain input steadily increases the resultant reflex muscle spasm and further pain generation of the dysfunctioning structures.

Somatic dysfunction vs abnormal illness

In the face of the impasse between professionals who diagnose and treat on the basis of somatic dysfunction, and those who diagnose and treat on the basis of abnormal illness or behaviour, evidence from clinical trials should be the key justification. It is in the selection and treatment of this evidence by the committees tasked with developing guidelines that we see the unconscious effect of theoretical allegiances and preconceptions. Evidence carefully testing the effects of rest during episodes of acute back pain is discarded and trials of lesser design and execution are included and over-interpreted. Without a strong theoretical preconception it would be difficult to see how the committees involved could have reached their conclusions. It must be acknowledged that rest has been over-prescribed in the past, though not in the main, it must be said, by osteopaths. Of course, like many effective treatments that can be costly and have side effects, it should be prescribed within rational parameters, which are clearly negotiated with patients. However, to discourage an individual patient from using an effective remedy for them is a serious error especially if the main justification is that this discouragement can be shown to have a beneficial total population effect; we treat patients as individuals.

What are the lessons to be learned from this situation?

Firstly, to realise that none of us can view evidence totally objectively: we all have a predisposition to see each observation from a prior conceptual viewpoint from which an alternative interpretation may not be apparent. When that viewpoint derives from a long education and experience, it may not be easy for others to share it. Consequently, while evidencebased healthcare is an aspiration we should all adopt, it should be qualified with the realisation of our propensity, almost inevitable tendency, to want our treatments to accord with our deeply held convictions. If a group has concepts that it believes are valuable and worth promoting, it must enter the battle of ideas and not expect any other group to provide the expertise or resources to produce the quite specific evidence that may be required. If it’s worthwhile, it’s worth fighting for.

In The Osteopath
Nota: Este artigo é apenas uma parte do artigo "The battle for ideas: a discussion" .

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