Evidence-based medicine

& chest physiotherapy

The validation of physiotherapy is based on the criterias  linked to the EBM : Evidence Based Medicine, which validates a disciplin  and a practice of medicine which also forms a reference for authorities in order to use health care funds at their best.

This concept is already applied in all the domains of medicine, it can also be applied to physiotherapy. Still it appears very academic and almost inapplicable in its strict meaning, risking to deprive some patients of potentially efficient treatments. Many patients suffer from a such mixed syndromes that disqualify them for the random controlled assays. This problem is linked to the particular methodology of the meta-analysis. The 2 following examples of CPT:

In the case the CPT in cystic fibrosis , two meta-analysis lead to two contradictory results. A first evaluation concludes on the useful role of CPT versus the absence of treatment (Thomas J. et al. . Chest physical therapy management of patients with cystic fibrosis. A Meta-analysis. Am J Respir Crit Care Med 1995; 151: 846-50.), another analysis indicates that the role of CPT is not clearly established (Vanderschans C. et al. Chest physiotherapy compared to no chest physiotherapy for cystic fibrosis (Cochrane Review). In: The Cochrane Library, issue 2, 2000. Oxford: Update Software). On the base of these works, doubt is allowed but the question remains : which doctor would dear to adopt an attentist attitude and so deprive his little patient from CPT treatment ?

The second example relates to CPT when applied to bronchiolitis in infancy. The analysis of the rare papers in English litterature concludes to the inefficacy of CPT, while two French papers in contrary plead in favor of CPT. A meta-analysis is here useless, due to the lack of works, it would probably conclude to a lack of arguments in favor of CPT. However, the "Conférence de Consensus Francophone sur la Bronchiolite du Nourrisson (Paris 2000)" concluded the other way, and recognized the role held by CPT on any other therapeutic measurement, medication being found inefficient and sometimes useless.

From the above examples, the lesson to remember is that clinical common sense must prevail. This attitude has the major advantage that it does not deprive any patient from a chance to benefit from a potentially positive treatment, that anyway seems to be on the clinical standpoint. The result should then appear as a subtle equilibrium between hardline application of the EBM and a more personal approach where the clinics itself, the experience of the PT and the bases of physiology feed the decision.

This permits to point out the interest of consensus conferences where arguments are less mathematical than the EBM process but rather leaves the place to convicting opinions . Like medicine, physiotherapy is also a science to be applied with art.

Our method contains a double approach : scientific arguments brought by the results of our studies, development of the clinical sense and collection of semiological parameters in the scope of the specific CPT assessment.

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