What’s prompted this blurb? Well I’ve had this conversation several times over the past couple of weeks. Albeit with a slightly different approach and with different people, but the basic question posited was the same … should we use ‘external devices’, lets say in rehabilitation practice?
Is there evidence-base?
Firstly, you’ve got to answer this question, right? If you go to the literature and you read that, say there’s no evidence whatsoever for the use of ultrasound; all recent systematic reviews and meta analyses show no benefit. Should we bin it? Probably a contentious example, but go with me,
Well clearly from an evidenced-based perspective, yes. However, what about the patient who has a strong belief that this magic machine helped with his symptoms and pain? Do you explain why he’s wrong and bin the thing?
Or, what about the patient who has knee pain and bracing helps alleviate it. Should we stand fast by our knowledge that bracing is bad because it causes muscle wastage through reliance on the support?
Don’t get me wrong, i’m most definitely NOT arguing against evidence-based treatment, far from it. I am, however, illustrating the importance of judging each case on an individual basis.
Clearly, any sensible person will evaluate each case on its merits. Yes, you may think that ultrasound is as useful as a chocolate teapot, but you have to be careful in how you disseminate this to the patient who’s come to you with statements like ‘they’ve received benefit from it in the past’.
In the bracing example, obviously we don’t want patients to become dependent on supports, but, if it provides a pain free window in which you can do some decent muscle strengthening work and rehab, that’s good, isn’t it? …and then we would hopefully be able to reduce their use of it over time.
Adjuncts to treatment
As I said, we should most definitely perform the treatments and interventions that have a robust evidence-base. But what about that grey area, where the evidence isn’t irrefutable, or perhaps where the evidence doesn’t exist yet? Whether you believe or not in dry needling, massage, manipulation, taping etc. I say, if it offers benefit (on top of your evidence-based strategies), which importantly downgrades their symptoms such that you can do some decent rehabilitation and as long as you’re not doing the patient harm and then why not? There’s a massive psychological component to feeling better, which is entangled in peoples’ beliefs and that we probably don’t truly understand.