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Dialogue on Evidence in Practice |
2806 E 16th Ave
Spokane, WA 99223
Thank you for the learned literature review and case example addressing lymphedema management in "Evidence in Practice" in the March 2002 issue of Physical Therapy. I appreciate your thorough research and logical decisions.
I do have some serious concerns, however, about the treatment choices that were made, based on my 7 years of experience in lymphedema management. Many of our patients fit the example—people with concurrent infection problems.
In a case such as the one presented in March, I believe that twice-weekly attention does not adequately cover our baseline tenet of doing no harm. In my experience, and given the lack of evidence in the literature to guide us, infection or other difficulties tolerating compression wrapping need to be monitored daily, especially in the initial 1 or 2 weeks of treatment. Dr Ciccone covers this problem by planning to instruct the patient in self-massage and bandaging so that she can provide self-care on the days when he does not see her and educating her about skin care and hygiene and safety precautions to prevent injury to the limb. How can this be done in two 1-hour treatments—in addition to examining her and determining her particular plan of care—when beginning hands-on therapy? I cannot cover all these aspects of care in this allotment of time for a patient such as the one described.
The article clearly exhibits our enormous need for us to publish clinical studies about our work in this field. At this stage, however, I fear that publishing guidelines such as these (which carry weight because of Dr Ciccone's name and reputation) may undermine our work. These guidelines will gladly be used by third-party payers to deny services that we fight so hard to provide. They will also give "weekend-educated" lymphedema therapists a false sense of the breadth of treating clients with concurrent medical problems.
Again, thank you for your scholarly consideration of an important matter. This case serves as a reminder of our need to produce clinical research and our need for care in drawing conclusions from the current paucity of information contained in our publications.
Division of Physical Therapy
The University of British Columbia
T-325-2211 Wesbrook Mall
Vancouver, BC V6T 2B5
Canada
The experience of seasoned clinicians, such as Ms Wing, is extremely important. In fact, such experience is embedded in the latest definition of evidence-based medicine (EBM) by Sackett et al: "The integration of best research evidence with clinical expertise and patient values."1(p1)
As the primary author of the Canadian clinical practice guidelines on management of breast cancer–related lymphedema that were cited in the March 2002 "Evidence in Practice,"2 I am intimately familiar with the evidence that framed the development of those guidelines.
In reference to the clinical management of lymphedema, Ms Wing stated that "twice-weekly attention does not adequately cover our baseline tenet of doing no harm." In fact, as the "Evidence in Practice" article pointed out, an Australian study published in 1996 showed that twice-weekly, less-intensive treatments were just as effective in reducing limb size as daily, intensive treatments.3 Are we perhaps "doing harm" to the patient's quality of life and to the cost of our health care system by suggesting that she receive more frequent treatment? What about the substantial costs to her personal lifestyle and pocketbook, when "current best evidence" suggests that twice-weekly treatment is every bit as beneficial as daily treatment?
Furthermore, Ms Wing worries that these guidelines will be used by third-party payers "to deny services that we fight so hard to provide." Once again, why would physical therapists, in good conscience, fight to provide additional services that have been shown to have no additional benefit for the patient? I believe that this is another example of why clinicians must integrate "the best research evidence" with their own clinical expertise.
Ms Wing justifiably calls for the need for additional clinical research based on "the current paucity of information contained in our publications." I wholeheartedly endorse this call! I strongly encourage Ms Wing (and other interested physical therapists) to replicate the Australian study, particularly because she serves a clientele similar to the participants in that study. In that way, she could contribute to the limited physical therapy research in this long-neglected area.
 | References |
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Editor—"Evidence in Practice" and Reviews
Physical Therapy
I thank Ms Wing for her insight and for sharing her personal experience in treating people with lymphedema. She may be correct in stating that it would be difficult to examine, evaluate, and implement a plan of care for this patient in only two 1-hour treatments; however, the literature search found nothing to indicate that physical therapists should use a specific (1-hour) time interval or that they should institute an entire regimen during the initial treatment session. Specific interventions could be added throughout the episode of care, with greater emphasis on self-care and the home exercise program being incorporated toward the end of the initial 4-week period.
Most importantly, however, I would like to emphasize that the clinical decisions described in "Evidence in Practice" articles are not practice guidelines. These decisions should not be interpreted as the singular or optimal management approach for a given condition. The purpose of "Evidence in Practice" is to illustrate the process for searching the literature to obtain and apply evidence about a specific intervention or other aspect of physical therapist practice—not to document or set the standards for best physical therapist practice.
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Physical Therapy 2002 82: 276-282.
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