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SPECIAL ARTICLES: O. Suchowersky, G. Gronseth, J. Perlmutter, S. Reich, T. Zesiewicz, and W. J. Weiner Practice Parameter: Neuroprotective strategies and alternative therapies for Parkinson disease (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology Neurology 2006; 0: 01.wnl.0000206363.57955.1bv1 [Abstract]

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Practice Parameter: Neuroprotective strategies and alternative therapies for Parkinson disease

Erwin B. Montgomery   (15 August 2006)

Reply from the authors

Oksana Suchowersky, Stephen Reich, University of Maryland   (15 August 2006)

Practice Parameter: Neuroprotective strategies and alternative therapies for Parkinson disease 15 August 2006
Erwin B. Montgomery, University of Wisconsin- Madison H6/538 CSC, 600 Highland ave., Madison, WI 53792 Send Correspondence to journal: Re: Practice Parameter: Neuroprotective strategies and alternative therapies for Parkinson disease montgomery{at}neurology.wisc.edu Erwin B. Montgomery	The usefulness of the guidelines in the article by Suchowersky et al on neuroprotective strategies is problematic. [1] Not necessarily because of the conclusions drawn but because of the curious inconsistencies in the logic applied. While applying evidenced-based medicine criteria to studies supporting a claim, it is curious that the same level of criticism was not applied to arguments undermining the claim. For example, the possibility that levodopa and dopamine agonists may affect SPECT and PET imaging of the dopamine system independent of the survival of dopamine neurons appears to be sufficient to discount the findings differences in SPECT and PET imaging following the use of levodopa and dopamine agonists. The question not addressed is the evidence in support of the counterclaim that the alternative effects of levodopa and dopamine agonists on SPECT or PET imaging are sufficient to account for the difference found in the clinical studies. Similarly, the claim that the symptomatic benefit of putative neuroprotective agents is sufficient to explain the outcomes of clinical trials have not been subjected to the same level of analysis. Is it reasonable that any flaw, theoretical or methodological, is sufficient to discount a study’s results? This approach may risk making the unattainable perfect the enemy of the achievable good. The danger is that such radical skepticism engenders therapeutic nihilism making it difficult for physicians to practice reasonable medicine in a regressive insurance climate. While decreasing the risk for errors of commission, it increases the risk of errors of omission. As to which is the lesser evil, this is a value judgment that evidence based medicine alone cannot answer. [2] References 1. Suchowersky O, Gronseth G, Perlmutter, J, Reich S, MD, Zesiewicz T, Weiner WJ. Practice Parameter: Neuroprotective strategies and alternative therapies for Parkinson disease (an evidence-based review). Neurology 2006;66:976–982. 2. Montgomery Jr. EB, Turkstra LS. Evidenced based medicine: let’s be reasonable. J Med Speech Lang Path 2003;11:ix-xii. Disclosure: The author reports no conflicts of interest.
Reply from the authors 15 August 2006
Oksana Suchowersky, University of Calgary , Stephen Reich, University of Maryland Send Correspondence to journal: Re: Reply from the authors osuchowe{at}ucalgary.ca Oksana Suchowersky, et al.	Dr. Montgomery argues that the usefulness of the guidelines are problematic and driven by radical scepticism resulting in therapeutic nihilism. [1] In fact, the development of therapeutic guidelines are the result of rigorous unbiased review of the published literature based on well-defined criteria. [3] The authors do not endorse therapeutic nihilism. Rather, the guidelines can be used along with many other sources, to determine the best therapeutic strategy for each patient. We refer Dr. Montgomery to an article by Dr. Guyatt for a more detailed review on the uses of evidence-based medicine. [4] References 3. Miller R, Edlund W. Process for developing Practice Parameters. 1999 AAN Quality Standards Subcommittee. 4. Guyatt G, Rennie D. Users’ guide to the medical literature. Essentials of evidence-based practice. USA: AMA Press; 2002. Disclosure: The article to which this correspondence refers provides the following disclosure: Dr. Suchowersky has received consulting fees from Teva, speaker fees from GlaxoSmithKline, and research funds from Boehringer Ingelheim, Kyowa, Merck, Amarin, Cephalon, Swartz-Pharma, and Solstice Neuroscience. Dr. Reich has received research funds from Guilford Pharmaceuticals and Cephalon. Dr. Perlmutter has received unrestricted educational funds from Medtronic. Dr. Zesiewicz has received consulting fees from UCB Pharma and Schwartz Pharma, speaker fees from Boehringer Ingelheim, GlaxoSmithKline, Novartis and Medtronic, and research funds from Boehringer Ingelheim, GlaxoSmithKline, Novartis and Merck. Dr. Weiner is a consultant for Teva, a speaker for Boehringer Ingelheim, and has received research funds from Boehringer Ingelheim and Teva. Dr. Gronseth has nothing to disclose.