Low Back Pain Guidelines- Evidence Based Practise

December 22, 2010 by   Print
Filed under Physiotherapy Blog

Here’s an 8 minute short video about clinical guidelines for low pack pain and clinical realty.

The mention of evidence based practice makes many clinicians lose the will to live. I have a love-hate relationship with this topic as I think it’s critical as a profession that we embrace the positive attributes of evidence based practice. However as I have expressed several times on these pages in discussions about evidenced based practice a distinction needs to be drawn between a lack of evidence and failing to treat patients in need. It is quite easy to feel assured (smug) with our management plan knowing that there is an evidence base behind our decisions. However, when research methodology fails to reflect the clinical reality then we are frequently left wondering whether the conclusions of such scientific research reflect what we are observing clinically.

When clinicians fail to apply evidence-based practice they are accused of being delusional or living in ivory towers. While some may stand fairly accused of this I feel the majority of clinicians are genuinely trying to help the patients who consult them. If one assumes that this is a logical starting point than I believe most clinicians establish specific functional limitations as targets for treatment and measure the effectiveness of the clinical intervention based on observation and patient feedback.

This seems to me to be a fairly obvious process and it should become clear very quickly if we are actually being of benefit. The issues arise when therapists fail to discipline themselves to critically evaluate their work and get stuck in a cycle of delivering treatment without any evaluation of the efficacy. Heat packs, shortwave diathermy, infrared lamp’s are obvious examples of palliative measures which might feel pleasant for the patient but rarely produce any tangible change in functional deficits – at least in my hands!

Much of the current trend particularly with regard to management of low back pain has been to establish clinical guidelines outlining current best practice. While much of this is well-intentioned much of the conclusions lack treatment specificity options and merely outline general management strategies or investigative approaches. The recurring phrase of nonspecific low back pain – which applies to 80% of low back pain population remains a convenient label to avoid evaluation or specific therapeutic interventions.

This situation has been compounded by the conclusion that most acute low back pain will spontaneously resolve within six weeks and that cases which are slow to resolve beyond this timescale need to be referred to a multidisciplinary management regime. This of course includes the patient population who been given general advice and instructed to read the “back book” in order to educate themselves on the issues involved in low back pain. This seems to me like a potential recipe for creating chronicity rather than treating the dysfunction and getting on with life.

Let’s not delude ourselves that all patient’s patients get better. Much of our work is spent trying to optimize patients functional capacity within parameters of their potential. This, of course, is a clinical judgment and does involve some element of trial and error – whether we like to admit that or not. I’m reminded of a recent quote by the Dean of the Royal College of Surgeons to a group of new graduates advising that they must always remember to practice the “art and science of medicine”.

I think such a public admission to an element of “artistry” (clinical judgment / interpretation) in the light of an increasingly sophisticated medical landscape is a profound acknowledgment of the multiple factors which come into play when managing patients.
Perhaps we as physiotherapist need to be more assertive by engaging in open discussion of clinical challenges, espousing the virtues of the test / re-test methodology which most apply in clinical practice and accepting that this process is one of the fundamental components of the “Scientific Method”. Let’s not be blinded by evidence based practice without question.

Enjoy the clinical challenge

David

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  1. […] have spoken before about the pitfalls of clinical guidelines in the management of acute low back pain.  […]

  2. […] with the clinical standards on low back pain guidelines suggesting that general advice is as effective as […]



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