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Since the publication of the ‘UK consensus on bladder management in multiple sclerosis (MS)’1 several articles have appeared drawing attention to the fact that our paper had so little evidence on which to base its recommendations. This was inevitable at the time, but the paper by Khan and colleagues2 in this issue has gone some way to redress matters by looking at outcomes of bladder rehabilitation in a randomised controlled trial (in press). In fact it is important to read this paper carefully since the authors' claim is that “a multifaceted, individualised bladder rehabilitation programme reduces disability and improves quality of life in patients with MS compared with no intervention after 12 months of follow-up”, not that any specific therapies are effective. The authors themselves refer to the ‘black box’ of rehabilitation and barely mention the actual interventions that were offered except to say that they were ‘standard’. I suspect this point may be overlooked by those needing to cite evidence for effective treatment in the future.
When asked to review this paper I was initially concerned by the ethical aspects of this study—was failing to treat bladder problems in patients with MS for a year really justified in the interests of evidence based medicine? However, if you follow the patient flows carefully (see figure 1 of their paper) you will see that of the 34 patients allocated to the control arm, 10 did in fact receive treatment, presumably from their general practitioners and neurologists with whom they continued to have regular reviews. The removal of a group of patients in whom treatment became imperative from the control arm could have introduced a bias in the results and lessened the study's statistical power but nevertheless the outcome was positive.
Although the force of argument for evidence based medicine is overwhelming and it would be difficult to overstate the importance of Dr Archie Cochrane's contribution to the scientific method of medical decision (http://www.cochrane.org/), there must surely be a point where insistence on evidence from a randomised controlled trial is not necessary? Perhaps I am an old fashioned, unreformed clinician but it would have run counter to everyday experience if treating people with troublesome bladder symptoms had not improved their quality of life. Happily the outcome of this rigorous study has shown it does and we now have some evidence to justify our earlier recommendations.
Competing interest None.
Provenance and peer review Commissioned; not externally peer reviewed.