Large, randomised controlled trials - the current trend in physiotherapy research - often show little to no difference between physiotherapy approaches in the management of musculoskeletal problems.
So said presenters at a congress symposium looking at the challenges and future direction of randomised trials in common musculoskeletal problems. However, the findings are often at odds with the experience of individual physiotherapists, who see patients improve, often dramatically, with specific approaches. While RCTs are considered the most appropriate tool for testing the effectiveness of interventions for common musculoskeletal problems such as back, neck, knee or shoulder pain, they are not without drawbacks and challenges. One challenge, according to the UK's Krysia Dziedzic, is that RCTs require that large numbers of participants be recruited quickly, so eligibility criteria must be broad. 'Narrower inclusion criteria, which theoretically should demonstrate more powerful treatment effects, make it more difficult to recruit patients and to generalise results,' she said. Danielle Van der Windt of the Netherlands noted that the perceptions, beliefs and preferences of both physiotherapists and patients could also influence outcomes, as can individual therapists' skills. Study results can be affected when it is not possible to blindly allocate patients or therapists to treatments. 'There are cases where patients drop out or are non-compliant with treatment when randomised to non-preferred treatment,' she said. Randomisation of individual patients may not always be possible when specific skills are required to carry out a complex intervention. Randomisation by group rather than individual patients may be one solution, said Ms Van der Windt, but it can be time-consuming and is not without other disadvantages. Another challenge is that RCTs usually present average treatment effects, but some patients may respond better to specific physiotherapy interventions than others. Patient sub-grouping is one option to account for this and is a future trend in designing RCTs, said Julie Fritz of the US. Symposium presenters agreed that physiotherapists should embrace a variety of study designs, and noted that the development of clinical guidelines may be one way to bring together RCT results in a way that is relevant to clinical practice.
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