I shared a systematic review in my previous article. When I shared this article with my fellow therapists, I thought I discovered the holy grail of Pediatric physical therapy research. Whenever I read any article or a research paper I would be completely awed by the mere effort the research team has put forward. This article in particular was a love at first sight. However, this excitement did not last many days. I came across an article by Trisha Greenhalgh Evidence based medicine:a movement in crisis? After which the systematic review discussed in my previous article proved to be my momentary hero/ my love interest while Trisha Greenhalgh’s article became a cause for my break up. It felt like a love at first sight followed by a fresh break up- with the idea of Evidence.
Refreshing the memoir of the systematic review in question, here were my first few impressions about the systematic review of interventions for CP :
- It fills a huge gap in the scientific literature. I’d never encountered such a large scale research where all possible research done on interventions for CP was brought together
- Easy interpret-ability, easy to remember- It has wonderful diagrams that basically sums up the whole research conclusion. You basically can have a look at the self explanatory diagrams.
- It has passed a rigorous criteria to be accepted in a well known journal as a systematic review which means it must be one of the best evidence available, isn’t it?
- It’s first of its kind research in Pediatric PT that attempts to compile/ bring together plethora of treatments available for children with cerebral palsy under a same roof.
- Oh Wow! it uses a wonderful grading system named as Evidence alert traffic light
Then I stumbled upon the heart breaking reality through the work of Trisha Greenhalgh. Below, I attempt to put together few of her points relating to what a real evidence should be:
- As much as we hate to accept, it is a fact that evidence based practice has been influenced by industries and pharmaceutical companies through biased funding and production of great volume of biased evidence. This needs to be considered while we look for evidence.
- Evidence must be usable – plain summary that can relate to clinicians and population who might use it
- Evidence should be individualized for the patient. We need to think about evidence with respect to patients circumstances.
As I dug deeper, I came across various interpretations/discussions of the systematic review (let’s say various faces of my love interest) through different departments. Some of the summary pitfalls on basis of these interpretations/discussions are:
Confusing Technical details:
- The research group based the systematic reviews on 166 other systematic reviews:
The number of these systematic reviews seems quite small when we discuss a condition such as Cerebral palsy which has many variations.
Many systematic reviews (25% as claimed by the authors) of major interventions discussed in the paper has not been taken into consideration eg orthopedic interventions and Neurodevelopmental therapy.
The volume and quality of the included reviews may have been influenced by pharmaceutical and industrial companies. eg. There are many research done to prove the efficacy of Botulinum toxins than other intervention.
- The research considers 64 interventions available for children with CP. The small number of researcher panel of may not be technical experts in the field of all the interventions taken into consideration.For example, orthopedic surgeries are totally different domain than physical therapy intervention.
- Many of the interventions which are conjunct to the CP interventions have not been taken into consideration
Judgment and clinical decision related issues:
- Cerebral palsy is an umbrella term with combination of multiple causative, clinical features and many associative conditions. The “Rule” provided as the product of this research might not be practically applicable to all CP conditions individually.
- In conjunct with the main stream management options, the adjunct therapy play a major role in intervention of children with CP. These intervention options like Behavioral therapy etc has not been taken into consideration. Does that mean that these interventions are not useful?
- The authors have confused the audience by allocating Hip surveillance as a “Green”/ important management option whereas the main stream management option for a possible hip dislocation, hip surgery, has been allocated a “Yellow” tag. This is controversial.
After my experience with evidence, I have few suggestions for my fellow therapists.
- Perceive Scientific evidence as “Best available evidence”- This evidence may be time dependent (as more facts are known, obsolete hypothesis and beliefs are changed/challenged)
- Never stop looking- keep reading
- Read articles and evidence with scrutiny- look for possible bias of evidence and question every details
- Research evidence must be clear- Do not let the jargon used in any research paper fool you. It is not a proof of a good evidence. For a evidence to be a real evidence, it should be usable by the target population (Other researchers, students, patients, clinicians)
- Research evidence must be applicable to your current practice
- Research evidence must be applied only after considering individual patient circumstances
- Be critical about the evidence provided to you. Do not fall blindly in love with the idea of evidence