The recent volcanic eruption in Iceland and the associated ash plume has devastated air transport in Europe for five days and looks set to continue.  Many issues have been exposed including massive price inflation in the hotel, car rental and catering sectors.  What has also become apparent is the breakdown in co-ordination of alternative systems like rail, bus, road and ferry transport as people have struggled to find other ways to move around.

This reminded me of a recent conversation on the topic of clinical guidelines of what our expectation are in relation to the guidance they provide.  In today’s climate it is hard to escape the reality of evidence based practice and as front line clinicians we are often confronted with the situation of a lack of evidence to justify a particular clinical intervention.

As the saying goes: lack of evidence does not infer lack of effectiveness – it may simply be a reflection that the necessary clinical trials have not been undertaken.  I was recently reviewing guidelines on the management of acute low back pain and International best-practised standards.  Let’s just review here the core elements that these guidelines make

What we know – Good Evidence…..

Avoiding bed rest

Early activity

Using activity quota’s to guide progression

Reduction of Fear & Anxiety

Advice

What we know – Moderate Evidence…..

Specific stabilisation

Spinal manipulation

McKenzie approach

What we don’t know – No evidence…..

Active Therapy

Muscle Stretching

Postural Training

General strengthening

Specific strengthening

Fitness

Work Hardening

Passive Therapy

Joint manipulation

Massage

Heat

Acupuncture

Electrotherapy

TENS

What struck me most about these best practise guidelines is just how general they are – which by implication means a glaring lack of detail as to what to actually do with a patient in front of us.  My academic colleagues tell me that this is the nature what guidelines are supposed to be.  My response is that if guidelines are so general and non-specific then do they justify the time, effort and status, which they currently receive?

The danger here is that if generalised guidelines are perceived / recommended as a clinical protocol then it is very easy to conform to principals and not do much with a patient. If current best estimates are that most “simple LBP” is self limiting and will settle in 6 weeks and the estimated recurrence rate is 30% (1 in 3) then how  is a policy of rest and NSAID’s then best possible care pathway – even allowing for “slow responders” to be offered supplemental physiotherapy?

This is not a popular assertion but undoubtedly there is a growing industry in reviewing literature, formulating guidelines and castigating clinicians who use treatment techniques that haven’t been scientifically validated. There is a potential conflict here between patient expectations, therapist delivery and 3^rd party payers (state or insurance company).

No doubt all clinicians would love the validity and certainty of knowing that every procedure that they do has been fully researched. I believe the Cochrane Collaboration best estimates of all surgical procedure efficacy is in the order of 15% – not an impressive endorsement but probable not a true reflection I suspect.

Like many things in life we may be striving for a Utopia which doesn’t exist.  This then raises the un-mentionable spectre of clinical judgement as part of the decision making process.  Before we pay to much reverence to the alter of science I am reminded of the inauguration speech of the current President of the Royal College of Surgeons in which he reminded all faculty members that they must continue to practise the “science and art of medicine” as it had been done through the ages.  I thought this was a particularly brave admission in these days where science is king and lack of certainty is derided.  If only everything in life was as certain as the scientists would claim wouldn’t things be easy?

Meteorologists tell us the volcanic ash is now clearing thanks to a fortunate change in wind direction. Let’s hope this extends to clinical practise!

Enjoy the clinical challenge

David.

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2010. | Permalink | No comment | Add to del.icio.us
Post tags: acute low back pain, clinical guidelines, clinical reasoning, Clinical trial, Cochrane Collaboration, Decision making, Evidence-based medicine, Health, medicine, NICE guidelines, Physical therapy, physiotherapy, Surgery

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