Evidence Based Medicine: Yes, No, Maybe?

Evidence Based Medicine: Yes, No, Maybe?

As a therapist, I try hard to practice evidence based medicine. I spend time reading articles, going to conferences, and discussing best practices with colleagues in the field. But what should I do or recommend when there is no consensus?

Hip surveillance and prevention of hip subluxation are popular topics for researchers right now. Kids with cerebral palsy who can’t walk are very susceptible to hip subluxation and this can become very painful. So, common sense says if we can prevent the subluxation, this would be good thing, and I agree with that 100%.

How to prevent it is the question. Clearly, we have lots of research showing that surgical intervention helps. A large number of my clients have surgery at differing times. Some have hip surgery early to try to prevent the subluxation. Others have it later in life after the hip is out and the results of that are less predictable. Some even have surgeries like selective dorsal rhizotomy or Baclofen pump implantation to lessen spasticity to try to prevent the muscles from pulling the hip out.

Surgery poses risks. From bad reactions to anesthesia to surgical infections, surgery is not a perfect answer for everyone.

What if there were things we could do to prevent the subluxation without surgery? Wouldn’t that be great? But what could help prevent it in these kids?

Pountney at al (2001) found that children who maintained hip abduction 24-hours a day in sitting, standing, and lying had a lower rate of hip subluxation. This sounded encouraging yet the data was not specific enough to give true guidance. The age range of the children varied widely from three years to eighteen years old and while some were followed for many years, some were only followed for a year. So, does this study tell us we need to keep everyone in hip abduction?

Macias-Merlo et al (2015) examined younger children who used a stander positioned in abduction. These children had a higher level of functioning (GMFCS III) and were already at a lower risk of hip subluxation based on their function. They looked at a smaller number of children and found that they did not have statistically significant results but that standing appeared to correlate with better hip positioning. So, with all of that, should we be standing kids in abduction?

I could bore you with a number of other studies with similar results. All have differing technical flaws. All concluded that standing in abduction is protective. So, do a lot of limited studies put together show this is the way to go?

Here’s my take. I agree that flawed research is flawed research. We should be holding the researchers accountable for this. Unfortunately many people reading these studies do not and they take them as proof of a benefit.

Considering the negative effects of hip subluxation on quality of life, wheelchair seating, and the ability to use standers once the hip is fully dislocated, I think we need to do everything in our power to prevent it. So, if there is a possibility that standing in abduction can help reduce subluxation, we should be recommending it. At the least, it can help to keep passive motion to assist with hygiene. At best, we have less kids who need surgery.

As a clinician, I’m hoping that we’ll see more standers on the market with the ability to abduct. Right now the options are limited and tend to be more for younger kids. Once they get older, we have no options to assist them to stand in abduction. If it is helpful, we need the equipment to accomplish it in all ages.

So I’m out there advocating for abduction for all of my non-ambulatory kids until I see research conclusively showing it doesn’t help. Now what to do with the article I just read today that says that manual muscle testing isn’t valid in stronger patients…back to reading more articles…the search to be sure I’m doing evidence based practice never ends.

References

Macias-Merlo et al (2015). Standing Programs to Promote Hip Flexibility in Children With Spastic Diplegic Cerebral Palsy Pediatr Phys Ther 2015;27:243–249)

Pountney,et al (2001). Management of hip dislocation with postural management. Child : Care , Health & Development, 28,2,179–185

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