Yes.....

dear Emilia,

let me first say how I appreciate your sharing your documents regarding in so many areas in our profession. Thank you.

Yes I also work eclectically and I think that is what most of us do when we have been in the profession for a longer period of time.

When following a (any) course, you can see (think of) the next patient you want to treat with this 'new method'. It happens every time and I hear this from colleagues during the courses I give as well.

Because of this, my ecletic approach is not yours, nor anyone else's. I have managed to make a mix of PNF,Bobath,Vojta,Sports,bindgewebsmassage,Manual Therapy, NDT-Mueller,Functional Therapy and lately et-taping etc etc etc... I have also included some of the wonderful things I have learned from energytherapists.

When a student does ask me what I am doing, it is not always easy to answer....

I am mixing so many theories/methods and practical skills & tricks of the trade, that it is truly hard to tell..... and of course I am using methods that they have never heard of or are not taught anymore.

Last but not least.... I am also including what I have learnt from the patients.

They are the true professionals regarding their own body.

I have learnt to not only listen carefully to what they are telling me but also be VERY aware of what their body is telling me. Example: the direction of the massage stroke... I now ask, which direction of the stroke feels best, I no longer do what I hypothesize to be the best.....

Your question could have two meanings - related but different:

1) where should such trials or comparisons be made, or

2) is there a role for combination of various approaches.

Both are good questions. I suspect the second is more in your direction. In my estimation as a researcher, it is likely that most patients need combinations. However, developing evidence for combining therapies is incredibly hard (relates to first interpretation). Nevertheless, the practice-based evidence approach (see the work of Susan Horn and others) can be used to develop sufficient evidence to conduct trials of various combinations. The issue is of course, there are an unlimited number of combinations to be tested. The best approach is to try to develop theoretical bases for each approach and use that to build models.

Hi Art,

I understand what you are saying but the daily practice in any clinic (I have witnessed so far) is that clinicians will mix approaches as soon as they have learn new ones.

Very Impossible to research I agree...

In the past I have been asked to treat a patient with 'method X Y or Z and have tried to do exactly as I was asked but I have noticed this is extremely difficult as in virtually impossible for me.

I have to be a type that can (choose to) forget the good new stuff I have learnt from the other methods and keep it to this ONE method. Something which is easy to do if you know only the one method I presume.

If it is the wish of researchers to analyse the possibilities of any given method, they would have to work with therapist that have only been trained in this ONE method and in nothing else.

In my opinion it is virtually impossible to keep methods apart once you know more.

Will look up the work of Susan Horn, for me a new name.... have just had a look here and have asked information straigh away...

Am familiar with a lot of work on functional physiotherapy/task specific therapy as I am Dutch and as you will know the Dutch have been busy in this area as well. We seem to want to PROVE everything.... EBM is the magic word....

As a clinician I have the obligation tot the patient and myself to:

keep up-to-date,

I also have the obligation to keep using all 'old' methods that have shown good results (with me using this method) in the clinic.

I am responsible for what I do. What I do cannot be compared to what my colleague does in any given situation.

For the researcher the problem is that:

every individual therapist is a variable

the same therapist on a different day = state of mind and body (after a fight at home, or a loss compared to happy or in love) is a variable

the patient is a variable

the patient's state of mind and body is a variable

the therapists' understanding of the (a) given method is a variable

the therapists' skill at any method is a variable

and that is before you even start to conduct a trail on any given method....

Trying to research combinations is making it really difficult .....

and then every bit of new information coming from research should be regarded a variable as well as it will influence my thinking and therapy and maybe change my way of looking at what I have been doing so far.

And then we haven't mentioned the 'like' factor so far...... does the patient like and trust me as a professional is a BIG variable as well....

The chasm between research and the clinic is still very very deep....

Maybe it is time to rethink research....

for starters...........

it might be an idea to start looking at why some therapists are so successful and others are not?

why some have fantastic results?

is it a result of certain mixes of therapies

what makes these therapists so good at their job?

and maybe start looking into how we could learn from them.....

I wish us all lots of wisdom

Susan Horn is based in Salt Lake City, Utah, USA. She is a methodologist who specializes in case mix adjustment and large data set analysis of very rich clinical and research data sets. She has worked on many medical research topics.

We in the International Society for Restorative Neurology (ISRN www.restorativeneurology.org) are very interested in developing knowledge based approaches using neuroscience and especially clinical neurophysiology to seek out the best solutions.

Thank you fro very important opinions. Of course almost each of physiotherapists have his/her own eclectic approach, determined by the own education, experience and particular patient. But we need:

- theoretical basement (=why does it work),

- clinical guidelines (=how to treat),

- evidences (=how to improve effectiveness according to EBM/EBP paradigms),

- how to teach (=how disseminate knowledge and experience),

- how to develop (= interprofessional education concerning all members of interdisciplinary theraputic team).

This problem is much wider than I thought several years ago. This year I discussed issue of influence of Assistive Technology (including brain-computer interfaces and neuroprostheses) to eclectic approach to intervention - I hope it will be published as a book chapter. In aforementioned area problem: balance between recovery vs. replacement of function may one of the important due to brain enhancement threats.

In my opinion eclectic approach, despite efficacy, needs for common effort and agreement.

I know and appreciate SD Horn work, but despite common effort evidences in neurorehabilitation still remain rather week. Example: we do not know why we intuitively percieve Bobath approach effective and we can't provide relevant evidence to prove it. The same in eclectic approach may be very difficult.

dear Emilia and Art,

So it seems we have a long way to go... I understand we need fundements to teach, to develop and to move on...

I for one see I have some more reading to do....

Had a quick look at the website Art mentioned and appreciate the goals of the ISRN has.

Great question since we seen the application of electrical nerve and muscle stimulation in wound healing, pain control, muscle rehabilitation and strengthening in sports but only recently has there been an application for the neuro patients. There has been a growing use of electrical stimulation (e-stim) for CVA patients to lift up the front of the foot rather than using a plastic or metal brace. In the correctional setting, we have been using e-stim for nerve damage following knife and bullet wounds with some success (observational).

These e-stim (based on the settings) will primarily stimulate fast twitch fibers so there is a real concern for early fatigue. Careful placement of the electrodes (uni-polar or bi-polar) can also be used very effectively. I would strongly encourage you to use the modality as an adjunct to your more traditional rehab approaches. My best to you on this endeavor! Pat Carley

It seems there is agreement we have proper questions here. We have to find answers now :-)))

It would be interesting to hear if Antony has an opinion on this... am willing to think out aloud with you all, but I am the clinician

Thank you for your question. It made me think of how rehab helped me in resolving some of my Fibromyalgia issues. I have to have a positive attitude of healing to be able to get better. I believe from what I have learned is that a holistic approach is needed with rehabilitation, physical or otherwise.

I bet this is a very good platform for such a discussion... as i am also wondering about the work of sandplay and rehabilitation... as we are having lots of patients with TBI

Nonetheless, rehabilitation is a new area which needs lots of exploration still..

I'm quite keen on the eclectic approach based on department protocols. I have seen some interesting pilot studies concerning the use of FMRI as a neuro feedback tool (visual reinforcement for the patient) to reduce the severity of tremor in patients with a CNS pathology. Looks promising!

dear Geok,

I have used sand, rocks, mud, bricks, shavingcream and a lot of other substances as a stimulus to achieve a given goal.... but I would not call using different material a method or approach as such.

dear Patrick,

in the 'old' days, we used to use every modality of electrical therapy lots and then we stopped using (in a number of countries). The e-stim you are talking about is regaining ground and I agree, it is a very useful tool and could be used more. The SLP's have discovered it and are using it.

dear Ben,

I wish the FMRi were available to everyone, but they are not. I am hoping that most Rehab Departments will have one, but I am not so sure.

I agree with you, that it is a fantastic extra tool but not only one that physiotherapists use.

dear Susan,

I agree with you that a holistic approach is favorable. Problem is, as stated before, that it is very therapist-bound and difficult to research.

dear Emilia,

I am not so sure we have asked all the questions yet.

Is it an idea to first sum up which methods/approaches we are talking about?

I understand your push to get some answers but what are we talking about?

I have been around for a while, worked in different countries and believe me, there are many differences in the way we percieve our profession. They are in part cultural, but also economical and personal. A number of things are the same of course, but I have seen many differences in the manner we treat and what we deem 'proper' physiotherapy.

And then.......

I have seen therapists, really specialized in a certain method perform little miracles.

I have seen highly qualified therapists, do no such thing.

I have seen highly qualified therapist not do a good job because they lacked emotionel intelligence.

Comparing countries is probably not possible either as:

the education systems are different,

the quality of the lecturers differs,

the (regardless of Bologna Agreement) curriculum will be different,

again the culture and economic state of a country differs

and entry levels to education differ.

I really think we need to make a list of what we regard to be the approaches we would like to 'mix' before we go any further.

Dear Esther

List you have poroposed may be important step in a proper direction. Of course so called eclectic approach provides tool(s) for holistic therapy, biopsychosocial approach to health care, personalized therapy, etc. - in area of my scientific interests (neurorehabilitation) I tried to explain it in my paper:

http://www.degruyter.com/view/j/ijdhd.2013.12.issue-3/ijdhd-2012-0103/ijdhd-2012-0103.xml?format=INT

I agree it may be impossible to provide common frame for ALL physiotherapists and patients. But it seems patient-oriented personalized medicine is the future (now it becomes somenthing common e.g. in oncology). Thus my general question are: is it possible to do the same in rehabilitation? Your opinions as specialists in various areas of rehabilitation are precious. I am aware a lot of questions associated with this issue. I think in the area of education former relationship master-apprentice would be the most suitable, but it is rather rare nowadays. It seems eclectic approach may be applied by the most experienced and well educated therapists - beginners will still use more traditional approach.

I tried explain it based on my own education and experiences (recently (I do not know if it is very useful way due to mentioned by you differences between countries, etc.):

- edcuation: MSc degree in physiotherapy, then PhD in physiotherapy and 4-years postgraduate course for governmental title of specialist of physiotherapy,

- postgraduate courses: basic and advanced NDT-Bobath for adults, basic and (now) Baby NDT-Bobath for children, PNF, Cyriax, kinesiology taping, workshops on rehabiltiation robots, gait, posture, balance analysis, etc.,

- 16 years of experience as physiotherapist, inlcuding 10 years with patients with severe neurological deficits, and 10 years in Bobath approach.

My knowledge and experience may be regarded as barely to think of joining various methods, techniques and tools in eclectic approach in neurorehabilitation (I am 39 years old, it may be difficult to achieve it much earlier). Moreover I do not know if my education and experience is the only possible way in neurorehabilitation. I do not know how to assess "profesional maturity". Very difficult objectivization (therapy, qualifications, experience, etc,) may be necessary. Each approach tries to be standarized to avoid mistakes and provide the best possible effectivity - see efforts of IBITA and EBTA (NDTA in the US) - it seems their certificates have similar value in various countries. It may provide possibilities for compartmental studies (see paper of M. Paci concerning e.g. need for compartment of Bobath therapists qualifications in CTs and RCTs). But a lot of Bobath therapist still use "eclectic" approach to Bobath Concept. You are right - there is still a lot of issues to explain. But we asked some important questions and it may be step toward further development.

I very much agree with you that we need to think of the future and try to use the knowledge we have now to improve future therapy for all patients.

I also agree with you that it is much more complicated especially the research regarding our profession.

THE biggest problem I see (and haven't mentioned so far) is when trying to assess physiotherapy is that we TOUCH people.

Just about everything we do is through touch....

As soon as we touch the patients' CNS is activated and so is ours.

Our skin is our outer brain as described by Tobin D. in 2006 in his article: Biochemistry of human skin- our brain on the outside Che,Soc.Rev.2006,35, 52-67)

We physiotherapists have used it, prodded through it, massaged it but to my knowledge we have never really stood stil and pondered on what the skin means to our profession.

Physical and psychological changes take place through touch and this wil influence the outcome of whatever we do and this is something that is not easily measured.

Research into a pil, a certain injection must be much easier, there are a lot less variables to take into account.

I am aware of the efforts the IBITA but also the IPNFA are making to standardize their programmes and undertake research but they have NO influence on how the general practitioner that has followed the course wil act in their clinic.

As an example; I am a Cyriax certified therapist but I only use one of the many techniques/positions and I have adapted this from a passive to an active position. I also use tape in this area and this seems to be having the same effects. What I learnt in the course helped explain a lot to me at the time, but that is not to say that I use the method as it was presented.

I have tried to go to the link to open your article but see that I would need to pay for it. Could you send me a copy? [email protected]

I wil read and come back to you on this then.

Done. Check your e-mail, please.

Thank you, will get back to you

That's is a good question. I believe that a holistic approach can really improve patient’s health and wellbeing, especially in patients who didn’t show improvement with conventional therapies. I think there are some evidences about this approach. However , costs for holistic-type treatments can be very expensive.

Hello, This is an interesting question and an important issue if physiotherapy as a profession is going to progress. For any claims about the effectiveness of any specific type of intervention there needs to be a clear description of the intervention and dosage of that intervention with measurement before and after the intervention to demonstrate that the intervention has been effective. It is meaningless to make claims about the effectiveness or superiority of any type of intervention without clear evidence of that intervention's effectiveness.

So called “eclectic” approaches are of no benefit to patients or therapists if they are not clearly described to enable other therapist to reproduce those interventions and achieve the claimed beneficial results for patients to achieve their desired goals.

It is essential that other therapists are able to reproduce the intervention and achieve similar improvements in function for that intervention to be of value to those we are treating. Specialist individual therapists are of no value to the broad needs of the thousands of patients unless they are able to teach other therapists their skills and provide those therapists with the necessary skills. The place to start is to describe accurately what we are doing, record the dosage of practice and measure the results. Once this starts to happen we will be able to begin to compare effectiveness of interventions and find optimal interventions for specific patient problems.

Evidence based intervention is the only way that our profession will continue to develop.

Dear Karl, in my opinion you are partial right, because rehabilitation and physiotherapy should provide the same high quality of evidences as other interventions, e.g. surgery or drug therapy. This is basement of evidence based medicine/practice (EBM/EBP) paradigm. But current evidences in e.g. neurorehabiltiation are still weak: therapy one therapist to one patient is rather individual, patient-oriented, there is common goal setting, and there is hard to provide randomized controlled trials of e.g. 30 (research group) + 30 (reference group) similar patients with similar disorders and similar therapy. CTs and RCTs are essential, but difficult to provide in the proper way, thus I appreciate case studies in neurorehabiltiation and as you I prefer case studies as both scientific and didactic tool and evidence how to reproduce therapy. But it may be difficult to teach this way a lot of students in many case studies.

Eclectic (mixed, etc.) approach may be necessary - combining of various methods, techniques, tools (by experienced therapists) may be more efficient than single method. We do not know it for sure now. Case studies may be hard to find, CTs and RCTs are really diffcult. But if we trust in power of the eclectic approach we need to check it, develop both neurophysiological basement, techniques and tools, ways of education, etc. for eclectic approach purposes. Power of modern rehabilitation and physiotherapy lies in further development, our own scientific research and cooperation of scientists.

why do you feel costs for holistic therapies are expensive OT's have been holistic since their inception.I feel that in rehabilitation to use a hackneyed phrase thinking out of the box is what works and that perhaps a return to the "older "more eclectic way of thinking is what is called for. There is danger that being a purist may not achieve the rehab goal. I recall a physio many years ago insisting on Bobath principles being used on the toilet! Using an electic approach requires abandoning the medical model and developing models of practice in which you can root your evidence . Hope that helps .

I suppose it was Mirella who wrote about expensive costs of holistic therapy.

In my opinion total costs of therapy and rehabilitation can not be described simply without costs of further care. It is not a rule, but if we spend more money on more effective rehabiltiation, AT, OT, etc. then costs of further therapy (including long term rehabilitation, home care, pensions, etc.) of better prepared and more independent patient may be lower. There is lack of accumulation of costs in long perspective. Thus total costs of holistic therapy may be even lower for whole society. It is another issue which need for research: if more effective (but in selected cases: more expensive) rehabilitation may be cheaper in the long perspective (five, ten and more years follow-up).

I am aware that contemporary hospitals, etc. run based on rather short perspective - it may promote (safer) procedural approach. According to the eclectic (mixed, individualized) therapy each patient is a new project, not procedure (thinking according to the project management theory and practice), thus it may be more effective.

I will tell you what is expensive: Not holistic at all, but allopathic. An unnecessary surgery to the neck can cost upwards $120,000 (US), while the much more effective and permanent work done via Class IIIb and Class IV cold laser, targeted live nutrients that build cartilage and bone, along with medical massage and occupational therapies, etc. costing perhaps $2000 for 12 weeks of treatment (US. We see it everyday and wonder aloud who can say holitistic is expensive? Compared to the trillions in unnecessary surgeries, toxic medication loaded with side/interaction/withdrawal effects, endless tests that show little of nothing--nearly all paid by someone else other than the individual, which is why in my opinion so much of this happens. Before governments opened the coffers wide open to any and all comers, this kind of medical malfeasance was rare, as the stakeholders had a say in it. Truly, for most long-term chronic conditions, CAM and holism backed by an an expanding universe of solid science is where it is at.

BTW, what Emilia might be referring to is when government coffers allow endless rehab without accountability for results, a one hour OT visit becomes a quick 15 minute once-over that benefits no one. We have a private OT clinic and see the lack of results coming out of the government financed clinics--paid by the visit and not defined by outcomes. That proposition is expensive and yields little for the patient.

The question of Emilia about joining elements of various specific intervention techniques (eclectic approach) within current rehabilitation is very interesting but answering this question is not so easy.

Rehabilitation of patients is a very complex process. I restrict myself to physiotherapy as one of most important part of rehabilitation. Based on medical diagnosis, referral diagnosis and referral data, the PT gasthers complementary information from the clinical history and by physical examination in order to obtain an impression of the pathway frommel diseases to the nature and intensity of the health condition - health problem, and the extent to which may Be actief upon. It is expected that this pathway progresses from pathology or disorder to impairments, disabilities, participation restriction, and quality of life. Different models for conceptualizing this progression have been introduced within rehabilitation. This diagnostic process is completed when the indication for physiotherapy has been established. The PT diagnosis should contain 'clusters' of: (a) the underlying disorder; (b) an estimate of the balance between load and load tolerance; (c) the psychosocial context of the health problems; (d) related impairments, limitations in activities, and restriction in participation; and (e) an estimation of the mechanisms of adaptation. It is the PT's role to confirm whether there is indication for physiotherapy treatment, and to determine what treatment tools and treatment plan will best suit the needs of the patient in accordance with the current state-of-the-art body of knowledge.

The next step is to formulate a treatment plan, existing of: (a) treatment objectives and outcome measures; (b) treatment strategy; (c) treatment modalities or techniques; (d) prognosis of treatment duration (including number of treatment sessions); (e) expected outcome.

Based on the result of complex considerations, the physiotherapist must determine which treatment procedures or combination of procedures will result in the greatest degree of anticipated functional recovery or compensated recovery of patients when functional recovery is not expected Making evidence-based choices for treatment procedures or combination of procedures has become part of the professional development of physiotherapy.

In summary, clinical reasoning of PT process helps the physiotherapist to determine which treatment procedures or combination of procedures are the right choice. Without this process as prerequisite, it is impossible for me to answer your question.

Excellent plan, Rob. Each nation is different in how they compensate and regulate (by compensation, licensure) rehabilitation. Our concern is that in the US rehab has been relegated to low reimbursement rates and too often replaced by addictive/delaying medications and unnecessary, but more readily compensated surgeries. This is making rehabilitation more challenging for the patient and for the professionals that take care of them. Perhaps there are pockets of exceptions here and there, but we do not see them in the mainstream.

clearly there is a need for re-evaluation. we are being told to look at becoming traded services and there is a challenge as to how to include quality of therapy within what is rapidly becoming a business model. This seems to be a journey similar to your selves. Currently I am looking at holistic outcome measures rather than intervention based in order not to loose site of the overall therapeutic effect . The individual approach measures such as ROM improvement (simplistically) can be used to dig down but purchasers just want to know does it work for the patient. The WHODAS is looking good but not clear on its validity with children as it appears under development in that age group. Anyone interested in collaboration?

I am so sorry. After rereading of the text I saw some errors that I corrected. Here the corrected text.

The question of Emilia about joining elements of various specific intervention techniques (eclectic approach) within current rehabilitation is very interesting but answering this question is not so easy.

Rehabilitation of patients is a very complex process. I restrict myself to physiotherapy as one of most important part of rehabilitation. Based on medical diagnosis, referral diagnosis and referral data, the PT gathers complementary information from the clinical history and by physical examination in order to obtain an impression of the pathway from disease to the nature and intensity of the health condition - health problem, and the extent to which may be act upon. It is expected that this pathway progresses from pathology or disorder to impairments, disabilities, participation restriction, and quality of life. Different models for conceptualizing this progression have been introduced within rehabilitation. This diagnostic process is completed when the indication for physiotherapy has been established. The PT diagnosis should contain 'clusters' of: (a) the underlying disorder; (b) an estimate of the balance between load and load tolerance; (c) the psychosocial context of the health problem; (d) related impairments, limitations in activities, and restriction in participation; and (e) an estimation of the mechanisms of adaptation. It is PT's role to confirm whether there is indication for physiotherapy treatment, and to determine what treatment tools and treatment plan will best suit the needs of the patient in accordance with the current state-of-the-art body of knowledge.

The next step is to formulate a treatment plan, existing of: (a) treatment objectives and outcome measures; (b) treatment strategy; (c) treatment modalities or techniques or procedures; (d) prognosis of treatment duration (including number of treatment sessions); (e) expected outcome.

Based on the result of complex considerations, the physiotherapist must determine which treatment procedures or combination of procedures will result in the greatest degree of anticipated functional recovery or compensated recovery of patients when functional recovery is not expected. Making evidence-based choices for treatment procedures or combination of procedures has become part of the professional development of physiotherapy.

In summary, clinical reasoning of PT process helps the physiotherapist to determine which treatment procedures or combination of procedures are the right choice. Without this process as prerequisite, it is impossible for me to answer your question.

.

dear Everyone,

Emilia has raised a question that cannot really be answered.

In my humble opinion there are too many differences per culture and per country.

I have worked in Holland, Spain and Germany and lived in Holland, Australia and Spain. Physiotherapy is not exactly the same profession everywhere. I have also seen this in the work I have been doing for the IOPTP. Much as we would like to think we are all doing the same, this is not always the case.

Our profession should keep on developing without throwing valuables (expert opinion) away, but even this development is different per country. There are too many variables:costs, various cultures, perception, status, institution or private practice to be able to compare and there is no quick fix or standard that will fit all.

I understand that as an educator you need to be on top of this all.

I don't believe there is ever a question that can't be answered otherwise why do research . Although I admit some are harder than others to find the answer to.I selected the WHODAS as it is validated in 40 countries taking into account the very variables Ester has mentioned. Certainly nothing measures the "gut " feeling that you only get from experience and that ability to join the dots that the clinically gifted have.

Its subjective and therefore harder to statically measure. We deal with human beings who are a huge mass of variables before intervention commences, worthwhile is never easy I for one will keep plodding away.

Sorry that I am a little later in the discussion. I said before that holistic, alternative therapies are expensive. I agree with Emilia “There is lack of accumulation of costs in long perspective.”

Depends on how the health system is organized and funded and the population SES it can be sometimes unaffordable. In many countries, population doesn’t have to pay for allopathic treatments. Usually, health systems don’t cover alternative treatments.

I also believe that holistic therapy is very effective and should not be expensive. It has been part of population’s treatments for ages.

Thank you Emilia for a good question. As everybody already suggested, it is a difficult one to answer. Like Esther, I have been in contact with different models of healthcare systems being from Belgium and living and working in Ireland. The different solutions provided are inherent to the organisation of each healthcare systems and national policies.

However, I see little said about prophylaxis when it comes to healthcare services and costs. Yes we need to help people who suffer from disabilities, injuries and illnesses but it is just as importantly to find a way to reduce costs of healthcare at the source. Take the simple example of obesity which is on the rise globally and that has been shown to be associated to a multitude of CV diseases. We now realise no national healthcare system will be able to cope in the near future if things remain unchanged. Thinking widely I believe what needs to be done is not only to look at the best mixed strategies to help our patients increasing their quality of life but more importantly, working in prevention is the only way to reduce long term costs.

I know I haven't really attempted to answer your question directly Emilia, but I just wanted to comment on the financial constraints that patients and society are facing in our current healthcare models. We need to rethink available resources or else fewer people will have access to any care at all.

An example of this in musculoskeletal therapy is provided by Bennell et al. 2011 (attached). The example builds a rationale for combining interventions into a package of care, for patients with osteoarthritis, that forms the intervention used in an RCT. The principles and framework described should be applicable to other conditions and other areas of therapy such as neurorehabilitation.

Xavier raised the issue of limited respurces and J. Abbott along the lines of optimal care. Both very valid concerns although juxtaposed in the paradox of public health policy.

The system in our country is depleted because egregious behaviors (overeating, GMO high fructose, tobacco, alcohol, high-caffeine, severe micronutrient deficiencies, toxic food additives, heavy metal accumulations, etc.) are left untouched while the chronic disease pandemics they bring rage on. We are the boat that is sinking because we are using a teaspoon to empty water from the boat instead of plugging the hole.

In the 2-3 minute average face time the patient has with their doctor, nurse practitioner, or PA, only the vitals can be scanned, scripts written, and nothing said about the consequences of chronic dehydration, smoking, polypharmacy, or consumption of (3) large adrenal-crushing Red Bulls a day. No matter the rehab program, three happen under this scenario: 1) the ship of healthcare is swamped, 2) rehab takes a distant backseat, and 3) vested interests depend on an increasingly sicker society to satisfy investors and bureacrats. Until we can undo this paradox we are stuck with rehab improving under limited resources and more and more dependent on the private market.

Nice topic, and very interesting discussion.

As clinician and researcher I frequently struggle to find evidence that support PT interventions for complex patients. PTs should invest in research aimed to provide a rationale for interventions directed to complex patients. They should constitute the future challenge for our profession. Frequently by reading clinical trial papers I saw inclusion/exclusion creteria to selected patients that are too far from clinical practice or not relevant.

Good answer Marco . How many times is the research hypothesis faulty or the patient being made to fit the criteria so the trial can go ahead ? The pressure is on to prove rather than do these days I see it on a daily basis in practice . We seem to be no longer about independence but about reducing risk. Where is the place for innovation when you are focused on no longer taking leaps in the dark. These days heart transplants would never have happened because someone would have done a risk assessment and said no.

Very nice discussion ideed. To bring back the focus on neurorehab, I just red a paper that reviewed different movement therapy interventions in stroke and also raised the lack of evidences for stroke rehab and the use of eclectic approach by therapists (Arya et al., 2011 see attachment).

The main question of this topic raised the fundamental problem between research and clinical practice (I am PT in an acute stroke care unit in Canada and also doing a PhD in neurorehab, so I can see both sides). In order to bring strong evidences (and first be published !), a research project needs to select a specific intervention, recruit a lot of homogeneous participants, use a randomized order with control interventions, etc. Evidences from the litterature are thus limited to one (or a few) intervention per study that do not represent the reality of clinical pratice (eclectic approach for heterogeneous patients). So, it is hard (even impossible) for therapists to replicate treatments demonstrated as efficient by research projects.

In my opinion, the question raised by Emilia could then be expanded to ''Is there a place for eclectic approach to intervention within neurorehab RESEARCH ?''

Any suggestions ?

I agree Louis-David , but I think as it was said before, sometimes it is hard to measure and access the effectiveness ( with a positive methodology) of some alternatives treatments.

Thank you for your answer. Maybe the solution for clinicians is then to use evidences from litterature as another tool box and try to adapt at best to the challenges that come with each different patients.

Dear Emilia,

I see that this discussion is already running some time. Nevertheless I am intrigued by your question. Some interesting and complex responses have been given. Still I would like to put in my contribution. The main thing is (in my opinion) to keep it simple.

First to answer your question: I think there absolutely is a place for eclectic approach. However this may not lead to unsubstantiated use of all kinds of techniques. It is essential that an underlying rationale is used to provide arguments as to why a specific technique is used. To do so you might want to use the next simple steps to build an ecclectic rehab therapy:

What you have to find out is:

1. What is the problem of the patient.

2. What does the patient need (or need to do) (and what is the best way)

3. What prevents the patient from doing so

4. What helps the patient in doing so

These deceivingly simple steps is all it takes.

Actually if you follow these steps you have complete freedom to incorporate whatever technique or approach you can think of. As long as it can be substantiated within the framework. Of course there are some (huge) problems related to these steps.

ad. 1. Due to insufficient scientific solid knowledge, workers in the medical field can have varying opinions on what might be the problem of a patient. An osteopath wil look at backpain in another way than a fysiotherapist or psychologist. So if you want to apply knowledge, techniques of a way of thinking from another discipline, you have to translate from the other discipines perspective to your perspective.

ad 2. Same problem here. What you consider the problem in the patient will drive your therapeutical approach.

ad 3 and 4. This is the psychological aspect of therapy. Here also there are very distinct views on what a patient should or should not do. (and how ...)

You might want to add a point 5: within which timespan do you want a result. This will help to remain critical a the ecclectic approach: does a technique contribute or not!

Thank you very much for appracition of my question and such valuable answers. All they influence my opinion in this area. I hope eclectic (mixed, etc.) approach will develop both toward deeper knowledge and researach and wider application in contemporary clinical practice in rehabilitation. We all may take a part in it - this discussion may incourage us toward it.

Hi Emilia

My clinical background is in hand therapy - the very nature of this profession is an eclectic approach, combining the skils and approaches of occupational therapists and physiotherapists. Additionally, as a hand therapist I treated acute and complex traumatic injuries, but also treated chronic conditions such as arthritis and hemiplegia. As such, you learn to adapt and borrow techniques from one arena and apply to the other, based on clinical reasoning, as Dr. Oostendorp and others so eloquently state. Now at this point in my career as a researcher, I am focusing on complex regional pain syndrome, a condition with no gold standards for diagnosis, a pathophysiology which is only beginning to be unravelled, and very disparate approaches for management supported by small studies. I find clinicians keep trying new approaches and adding in elements from several approaches because they do not have confidence that any one approach is helpful. My response to this - and I hope my contribution to this discussion as well - is we need to go back to the theoretical basis of each approach and make sure we are combining treatments that share the same view of the problem. Otherwise, there is a risk that we are working at cross-purposes, and even worse, we are giving our clients no clear message that they can understand. Since much of rehabilitation involves what we teach the client to do for themselves, we must not neglect the importance of patient education based on a common theoretical approach as the unifier for an eclectic approach. Once we have done the thinking through at this level, then the research also becomes clearer, with a rationale for what outcome measures can tap into the important theoretical constructs.

Thank you for starting this interesting discussion!

I might add that inclusion of deep cold laser (Class 3b and Class 4), along with some way to raise cellular oxygen (especially at site of lesion) would be a valuable addition to just about eclectic therapeutic approach. More than 150 studies suggesting efficacy and safety come out each month on this increasingly utilized technology.

Tara Packham had mentioned the importance of patient education. I believe that an important element of treatment is education, but i also believe that there are several factors beside knowledge, that may influence patient adherence. Treatment should be tailored to each patient'.s needs.

Yes, Mirella. Treatment without patient education comes back to the reductionist model, and not very effective or lasting in rehabilitation. Getting patient commitment to the goals and willing to make the necessary lifestyle, dietary, stress management changes in their treatment plan is paramount.

The adjective "eclectic", unfortunately, reminds two concepts: 1 "apples&oranges"; 2 non-replicable mixtures: may be of an artistic level, but not scientific as far as they are not replicable. As long as "clinical medicine -like rehab- is an art" or "more than science" it cannot be a true science. The solution is validating standard decision trees, not home made "brews". Perhaps the most familiar example is the "triage" assigning emergency codes in first-aid departments (if/then; if/then...and you reach a final decision: white/green/yellow/orange/red). The concept is assigning to each patient an individual "cocktail", but the cocktail is prepared according to reproducible (and validated) rules (the "decision split point", or "nodes"). This entails a wider methodologic view (which are the outcome variables, how to measure through questionnaires, what are the proper statistics etc: nothing which annot be found in medical and (more often) in social science. The Biomedical model : "one treatment to many people and look at change in the man", must be paralleled by the model "many treatments to one person, and look at achanges in individuals". It's a shift in a mental paradigm. Just invest along this line, and results will come. Start thinking, for instance, to the possibility to validly measure "change" in ndividuals rather than in populations: and an interesting horizon will open out to rehab research (see attachment).

Dr. Tesio,

Thank you for this article. A wider methodological and measurement view is certainly needed in rehabilitation. To address Emilia's original question about mixing physiotherapy techniques-- Bobath and NDT, I am going to add a personal story. In 1997 my husband had a severe stroke. At three days post, he was not a candidate for rehab ( early middle cerebral infarct, with lesion about the size of orange in cortical and white matter, incontinent, severe aphasia, and right side hemiplegia) I took him home and hired private speech, physio, and OT. We had a wonderful Bobath phsyio and when I suggested weights and more intensive training, she was keen to try. Her comment was, "But, we won't know what worked or works." She is absolutely right, we don't know why some patients with very severe impairments make remarkable recoveries and others with minor impairments don't resume participation.

There has to be a better way to look at outlyers, enriched environments, and those creative (and gifted) therapists who understand individual needs.

I need to talk about gifted therapists as well. To use an an analogy-- my husband was a computer programmer. There are very gifted programmers that will code 1000 lines of code compared to the usual coder who produces about 100 lines of code per day. Similarly, one surgeon in the class just had gifted hands! He did things that others just couldn't do and had far superior outcomes. So in the example of the triage in emergency-- all the surgeons could have started with the same injuries on similar age patients and done the same procedures-- but his patients always did better. I am sure that less time, less blood loss, and defter cuts and a very gentle hand with the muscles and organs were and will continue to be part of his success.

So change in individuals, but also the differences in therapists and slight changes in "standard" therapy also need to be measured.

Gentle is always better, as you noted, Sharon.

very interesting discussion - currently standardisation of outcome measures should make a level playing field between therapists. However its true that some therapists

do get spectacular results when the rehab prospects are not indicated as positive.How we could measure the factors involved in what makes these "super" therapists would make a good research project in its self. Our profession looks at examples of best practice and learns from them but this seems to involve other factors. Is it enviroment ,resourches, trainning, creativity , experience ? Food for thought. I think its true to say that everyone should be given the opportunity to reach their full potential.

Hi Crosby,

I think the measures for good therapists should be based on their competencies. It can be related a set of components such as clinical, knowledge, professionalism, and other abilities defined as necessary for the profession.

Yes we need to look at the methods, we need to look at combinations but .....

I think that it might be a really good idea to start seriously looking at what makes these 'gifted therapists' tick and how they got to become one.

A huge brain drain is on its way (in northern european countries) and if the young colleagues do not take advance of the knowledge that is out there at this moment, a lot will be lost.

Very stimulating discussion.

One aspect that has not yet been referred to: therapist patient interaction.

Interaction with patients is different between therapists. Even an expert therapist from a technical perspective may have trouble communicating with some patients.

The 'better' therapists may have more flexibility in choice of communication strategies with patients. This can be learned but only to some extend.

The Post Stroke Rehabilitation Outcomes Project used a research protocol that might address these complexities (patient mix/ patient therapist interactions/ therapist skills/ rehabilitation techniques).

http://www.archives-pmr.org/article/S0003-9993(05)01276-1/abstract

The problem is that in addition to complexity, this type of research is expensive and requires co-operation across countries and rehabilitation facilities.

I think this project only touched many of the elements related to better stroke outcomes. Often there are some gems buried in the text. For example, there are a couple of lines about a concentration on impairment based rehab for women (i.e., sit to stand, bed to wheelchair transfers) and functional rehab for men. As Esther and Jan-Paul pointed out, small differences that make a large impact.