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Editorial: A New Research Model for Orthopaedic Manual Physical Therapy

Editorial: A New Research Model for Orthopaedic Manual Physical Therapy

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Editorial on the introduction of the ADTO-Research Model as a more appropriate model for orthopedic manual physical therapy research
Editorial on the introduction of the ADTO-Research Model as a more appropriate model for orthopedic manual physical therapy research

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Published by: rapannika on May 07, 2009
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02/01/2013

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 a new Mel f othpec Mul Thepy resech:descpt  implcts
Despiteoraysintoediting,consulting,andteaching,Istillconsidermyselrstandoremostaclinician.And,atthat,Iliketothinkomyselasanevidence-basedclinician.Formethisappreciationotheimportanceoresearchinmyday-to-dayclinicaldecision-makingdidnotcomeeasy.Myentry-leveldegreeinphysicaltherapystronglyemphasizedauthority-basedknowledgeandclinicianexpertise.Iconsideredcoursesinresearchmethodologyandstatisticsascurriculumllersandmerelipservicetothesupposedscienticoundationomynewproession.Butwhocouldblamemeorthisnegativeattitudesome20yearsagowhentheresearchbasisorphysicaltherapywasverymeagerindeed?Andevenitherewasanyrelevantresearch,itcertainlywasnotintroducedtomeduringmyearlystudies.Icontinuedonwithgraduatestudiesintheareaoorthopaedicmanualtherapy(OMT)andbythen—muchtothecreditothephysicaltherapyproessionand,ocourse,ochiropractic,medicine,andosteopathy—theamountorelevantresearchhadskyrocketed.However,theclinicalvalueoresearchstillcontinuedtoeludeme.Thiswasnotbecausemyproessorswerepooratconveyingthecentralconceptsandmethodstome.Anditalso,althoughIwouldbethersttoadmitthatIamcertainlynostatistical“wunderkind,”wasnotbecauseIailedtounderstandresearchmethodologyorstatisticalprocedures.ItwasthelackoconcordancebetweenwhatIsawintheclinicandwhattheresearchwastellingme.AlthoughIoundthatOMTwashighlyeectiveorasubsetopatients,theseadmittedlyan-ecdotalobservationswerenotrefectedintherandomizedtrials,systematicreviewsandmeta-analyses,orclinicalpracticeguidelinesIread. Withmyby-nowexpandedknowledgeostatisticsandresearchmethodology,Itriedtomakesenseothisdis-crepancybetweenmyclinicalobservationsandthepublishedresearchonOMT.Ocourse,therewerethestandardargumentsomisrepresentationintherandomizedtrialsointerventionscalledphysicaltherapyandOMTthatinno wayrefectedwhatweactuallydoinclinicalpractice.Then,withnoonebeingquitesurewhattheeectivecomponentisinmanyOMTinterventions,therewastheuseoinappropriatecontrolgroupinterventionsthatmayhavehadun-intendedtherapeuticeects,therebywashingouttheeectotheexperimentalOMTinterventions.Finally,therewastheproblemthatthegenerallysmallsamplesizesinOMTresearchpredisposedthesestudiestotypeIIerror
1,2
. Withregardtosystematicreviews,Iquestionedthecomprehensivenessotheliteraturesearch;aterall,aairamountoresearchinthisareaisnotpublishedinthemoreeasilyaccessibledatabasescommonlyusedinsuchre- views
3
.Thenthereweretheconfictingresultsbasedontheuseodierentmethodologicalqualityassessmenttoolsdespitenearlysimilarliteraturesearchresults,oversamplingodatathatwaspublishedmultipletimes(perhapsini-tiallyasapilotandlaterasalargerstudy),and—perhapsmorenoticeabletoanon-nativeEnglishspeakerlikeme—thebiasoincludingonlyEnglish-languagearticles.Withregardtometa-analyses,therewastheissuethatstatisticalpoolingisonlypossibleitheincludedstudiesaresucientlyhomogeneous.Ithestudiesareheterogeneouswithregardtoclinicalparameters(e.g.,sample,intervention,outcomeassessment)ormethodology,thenpoolingisim-possible.Yet,statisticalproceduresusedtotestorsimilarityothestudiesincludedhavelimitedpowertodetecthet-erogeneitywhenthereviewsincludeonlyaewstudiesandtheseewstudiesagainhaveonlyewsubjects,asituation verycommoninOMTresearch
4
.Andthenthereistheactthatsystematicreviewsandmeta-analysesoninterventionuserandomizedtrialswiththeirspecicweaknessesasdescribedabove.Nowonderthereissuchahighproportionounreliableorpoorlyreportedreviewsbeingpublished
5
.SoIwasperectlycapableoprovidingseeminglyvalidcriticismsotheavailableOMTresearchbutasaresult,Ialsooundmyselevenmorewithoutanyresearch-basedguidanceorclinicalpractice.TruetomyproverbialDutchstubbornnessIduginmyheelstondasolution:howcouldIbeanevidence-basedclinicianiIhadnogoodevidencetoguideme?Willingorunwilling,readerso
 JMMT 
havehadarontseatinmy
 EDITORIAL
The Journal of Manual & Manipulative Therapy Vol. 15 No. 4 (2007), 197–199
EDITORIAL / 197
 
198 / The Journal of Manual & Manipulative Therapy, 2007
personalquest:mycriticalenthusiasmorevidence-basedpracticeintheeditorialsIhavewrittenoverthelastthreeyears;myincreaseduseodataonreliability,validity,andresponsivenessaspartomydecision-makinginthecasereportsIhave(co)authored;anincreasinginterestin,atrst,narrativeandthensystematicreviewsodiagnosticutilitystudies;andperhapsmosttelling,myattemptsatcombiningthevariousrecentclinicalpredictionrulesrelevanttoOMTwiththebiomechanicalandneurophysiologicalmodelsthatormedthebasisomyOMTeducation.Ithereisonethingthatclinicalpredictionruleshavemadecleartome,itisthattheimpetusorOMTresearchneedstobethedescriptionandvalidationopatientsubgroupsbasedonatreatment-basedclassicationsystem.RecentlyIreadanexcellenttextbyDonelson
6
,whereinhediscussedtheADTO-researchmodelrstdescribedbySpratt
7
.TheacronymADTOstandsorAssessment-Diagnosis-Treatment-Outcome.Theresearchmodeldescribedthreeessentiallinks:1.Assessment-Diagnosis:Thisrstlinkistheundamentalstepoestablishingintra-andinterraterreliabilityotheidenti-cationoaproposedsubgroup.2.Diagnosis-Treatment:Oncewehaveshownwecanreliablyidentiyasubgroupwithinatreatment-basedclassicationsystem,wethenneedtodetermineithissubgroupindeedrespondsconsistentlyandavorablytooneormoreproposedmatchedinterventions.3.Treatment-Outcome:Inthisnalstep,wedeterminewhichotheinterventionsshownecaciousinthesecondstepisinactthemostecacious.ItiseasytoseewherethevariousOMTresearcheortsandstudymethodologiesallwithinthismodel.Whereastherststeprequiresreliabilityresearch,thesecondstepwouldbebestservedwithobservationalcohortstudies,andthelaststepis wheretherandomizedtrialhasitsplace
6
.Thismodelalsoocusesourresearcheorts.IaparticularschoolothoughtwithinOMThasahypotheticalmodelthatdenestreatment-basedgroups,theirrsteortshouldbetovalidatethosesubgroups withresearchintothereliabilityothisproposedclassicationsystem.Inoreliablesubgroupcanbeidentiedbasedontheexistingconsensus-derivedcriteria,thenthesecriterianeedtobere-evaluatedandadjusted.Thismaymeanthatweneedtoletgoosomeoourmostprizeddiagnostictools,suchasmotionpalpation,orperhapsdecreasetheemphasisweplaceonitsndings.Ultimately,ailuretoshowreliablesubgroupclassicationwouldleadustoquestionthetheoreticalpremisesbe-hindtheapproach.Aterreliablesubgroupsareestablished,thediagnosis-treatmentstepwillthenalloworcohortstudiescomparingtheoutcomeointerventionsmatchedtothespecicsubgroupwith,orinstance,thesameinterventionorpa-tientsnotidentiedasbelongingtothatsubgroup.Cohortstudiesaremorerepresentativeowhatwedoinactualclinicalpracticeandshould,thereore,beeasiblewithinoneormultiplecenters.Consistentndingsinthosecohortstudiesinsup-portotheproposedtreatment-basedclassicationcanthenbetestedintherandomizedtrial,themostlabor-intensiveandcostlydesign,inthenalstep.Theresultanthomogeneouspopulationsinthesetrialswillmostlikelyshowtheresultsthat weclinicianshavebeenobservinginpracticebutwhichusedtobe“washedout”intheoldertrialsdescribedabovewiththeirmassiveheterogeneitywithregardtostudysubjects.Inapreviouseditorial
8
,Iexpressedexcitementthatrecentresearchhadprovidedme—asanactiveclinician—withevi-dence-basedguidelineswithregardtodiagnosisandmanagementoatleastsomeothepatientswhocometoseemeorbackandneckpain.HavingbeenintroducedbyDonelson
6
tothisADTO-model,Indanotherreasontobeexcitedaboutthesepre-dictionrules,astheysoobviouslytwithinthismodelthatIbelievewilldriveutureresearchwithinoureld.However,truetomyever-criticalnature,Iwouldalsodampenmyownexcitementwithacaveat.Onlyoneothepredictionruleshasaso yetbeenvalidated
9,10
.Atthat,validationoccurredinapopulationandsettingandwiththerapiststhatwerenotverydierentromtheoriginalstudy,leadingustoquestionthemoregeneralapplicabilityothisruletoamorevariedpopulationopa-tients,settings,andtherapists.Wealsoneedtoconsiderthatthesuggestedtreatment-basedclassicationsystemsuponwhichtheserulesarebasedarederivedbywayoexpertopinionandsubsequentconsensus.ThecategoriescurrentlyincludeddonotrepresentallcategoriesproposedwiththevariousOMTschools,mostnotablyaspecicmanipulationandamyoascialpainsubgroup.IamnotsayingthatsuchgroupstrulyexistbutIamsayingthatcurrentresearchintoclinicalpredictionrulescannotbeusedtoexcludetheexistenceosuchgroupsandvariousotherproposedgroupswithdierenttreatmentimplica-tions.Itisuptoproponentsosuchsubgroupstostartproducingtheresearchtoprovetheirexistence,andtheADTO-modelmayprovidetherameworktodosuchresearch.Talkingtooneomyormerstudentsrecently,Ilearnedoacompany-wideinitiativetoeducatetherapistsintheuseotherecentpredictionruleswiththeintenttohavetheserulesdictateclinicalpractice.Iamquitecertainthatsuch“evidence-driventotalitarianism”wasnevertheintentotheserules.Aterall,asBeattieandNelson
11
havealreadypointedout,clinicalpredictionrulesarenotclinicaldecisionrules.Predictionruleshavethepotentialtosignicantlycontributetotheclinical

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