When should we adopt a new therapy?


When should we adopt a new therapy? This is a vexed question for me. New therapies should be more effective, less time-consuming, have fewer negative effects or take less effort than old – or at least offer something positive – before they’re adopted.

I’ve been critical of the way new therapies have come and then gone in pain management to the point where I’m just a tiny bit hesitant to try a new approach until… well that’s the point of today’s post!

There are a few factors I find myself using to review a novel therapy.

The first is to establish whether it really is a new therapy – perhaps what is being called ‘new’ is merely rebranding. Often I’ll go to Cochrane Reviews or similar to see whether the treatment has been reviewed before under another name. The ‘gold standard’ for evidence-based practice is that there have been a good number of randomised controlled trials, preferably double-blinded, that have replicated strong effects in different populations from different settings. This level of evidence is pretty difficult to find in psychological therapies, and I’ll usually read a Cochrane Review only to find the authors asking for ‘more research’! Despite this, it’s surprising how often I’ll find that a ‘new’ therapy has been included in the past, and there are some useful comments within a Cochrane review.

The next thing I’ll look at is whether the new therapy is simply an old therapy being transferred from one disorder to another – a good example of this is the implementation of graded exposure for pain-related anxiety and avoidance. Graded exposure has been widely used in anxiety disorders. With the adoption of a similar theoretical model of avoidance in chronic pain, transferring the same approach from one disorder to another is relatively straightforward, with provisos. It can provide a way to test hypotheses about the mechanisms operating in a person’s presentation – but I’ll usually want to see some randomised controlled trials, or at the very least some clinical trials of the approach before I want to use it on a regular basis.  I don’t really want to experiment on my patients.

If it’s a really novel approach – for example, motor imagery for complex regional pain syndrome – I want to read some of the original research and review the proposed mechanisms the new approach is thought to be using. I’m wary of adopting a new therapy when there is only one researcher publishing findings, or when the clinical group it has been used with is different from the people I see. Anecdotes, or case studies, are the weakest level of evidence on which to base treatment decisions.

Some resources
If you’re new to thinking about evidence based health care, this website by University of Minnesota offers a two-part tutorial. Bandolier website offers a huge range of topics on evidence based health care, and the most recent update includes information on neuropathic pain and also fibromyalgia.

Cochrane Collaboration has the reputation as being one of the most critical review processes, although individual reviews vary in quality – overall, however, their reviews are well-regarded and worth a look first.

To simplify your search, this website SUMSearch, is provided by UT Health Science Center, San Antonio, and trawls through a number of search engines to find evidence based information on health care.

For some great links to internet databases, go to (the) health informaticist – and read their regular blog posts too for some thought-provoking and often chuckle-making commentary on things informational on the net.

**Quick rant**

What really bugs me is when there is a good level of evidence to suggest that a specific intervention has no effect or has a limited effect, therapists continue to recommend it!  A case in point is the use of splints for rheumatoid arthritis.  Another is back braces.  And another is carrying out ‘safe manual handling’ training to prevent back pain.

A therapist once said to me ‘if we stopped using all the things that don’t have evidence, we wouldn’t have anything we could do’ – erm…that’s the point I’m trying to make!  Perhaps not intervening at all is a more helpful option than continuing to do something that has no effect.

**End of rant**

More on science and therapy this week – if you’re not keen on science, be afraid, be very afraid!

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