Guidelines

Knowledge Transfer within the Canadian Chiropractic Community. Part 1: Understanding Evidence-Practice Gaps

By Frank M. Painter|April 9, 2017|Guidelines, Knowledge Transfer|

Knowledge Transfer within the Canadian Chiropractic Community. Part 1: Understanding Evidence-Practice Gaps

SOURCE: J Can Chiropr Assoc. 2013 (Jun); 57 (2): 111–115

Greg Kawchuk, DC, PhD, Paul Bruno, BHK, DC, PhD,
Jason W. Busse, DC, PhD, André Bussières, DC, FCCS(C), PhD,
Mark Erwin, DC, PhD, Steven Passmore, Hons BKin, DC, PhD,
and John Srbely, DC, PhD

Associate Professor and Canada Research Chair
in Spinal Function,
Faculty of Rehabilitation Medicine,
University of Alberta

Overview

This two-part commentary aims to provide a basic understanding of knowledge translation (KT), how KT is currently integrated in the chiropractic community and our view of how to improve KT in our profession. Part 1 presents an overview of KT and discusses some of the common barriers to successful KT within the chiropractic profession. Part 2 will suggest strategies to mitigate these barriers and reduce the evidence-practice gap for both the profession at large and for practicing clinicians.

Introduction

New knowledge is created at such a rapid pace that health care professionals find it difficult, if not impossible, to keep up to date. In a single day alone, 75 clinical trials and 11 systematic reviews are published. [1] As a result, it is incredibly difficult to keep up to date with the literature in order to implement new knowledge that may optimize patient care, increase benefits, or reduce harm. In an effort to promote evidence-based practice, many researchers and funding agencies are now focusing on processes to deliver emerging evidence successfully to clinicians and other stakeholders; this process has been termed KT.

What is KT?

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Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain

By Frank M. Painter|February 15, 2017|Guidelines, Low Back Pain|

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians

The Chiro.Org Blog

SOURCE: Annals of Internal Medicine 2017 (Apr 4); 166 (7): 514–530 ~ FULL TEXT

Amir Qaseem, MD, PhD, MHA; Timothy J. Wilt, MD, MPH;
Robert M. McLean, MD; Mary Ann Forciea, MD;
for the Clinical Guidelines Committee of the American College of Physicians (*)

From the American College of Physicians
and Penn Health System,
Philadelphia, Pennsylvania;
Minneapolis Veterans Affairs Medical Center,
Minneapolis, Minnesota; and
Yale School of Medicine,
New Haven, Connecticut.

The American College of Physicians (ACP) released updated guidelines this week that recommend the use of noninvasive, non-drug treatments for low back pain before resorting to drug therapies, which were found to have limited benefits. One of the non-drug options cited by ACP is spinal manipulation.

Chiropractors, who diagnose and treat musculoskeletal disorders, are experts in spinal manipulation.

This is just one article from a series of 5:

The Non-pharmacologic Therapies Low Back Pain

On May 1, 2017, the New York Times published an editorial by Aaron E. Carroll, M.D., that mentions the new guideline in a generally positive light. The article appeared in a major, mainstream publication read by millions of people. “Spinal manipulation — along with other less traditional therapies like heat, meditation and acupuncture — seems to be as effective as many other more medical therapies we prescribe, and as safe, if not safer,” he wrote.

Talking points on new ACP guideline:

The chiropractic profession has advocated for decades that conservative care choices such as chiropractic be the first line of treatment for low-back pain. Now, with this new guideline, the medical profession is recognizing the benefits of conservative care for this common problem.
Thanks to this guideline, it’s possible more medical doctors will choose to refer their patients with low-back pain to chiropractors.
The ACP guideline was adopted by the American Chiropractic Association, which also adopted the Clinical Compass guidelines on chiropractic for LBP at its HOD meeting in March.

DESCRIPTION: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on noninvasive treatment of low back pain.

METHODS: Using the ACP grading system, the committee based these recommendations on a systematic review of randomized, controlled trials and systematic reviews published through April 2015 on noninvasive pharmacologic and nonpharmacologic treatments for low back pain. Updated searches were performed through November 2016. Clinical outcomes evaluated included reduction or elimination of low back pain, improvement in back-specific and overall function, improvement in health-related quality of life, reduction in work disability and return to work, global improvement, number of back pain episodes or time between episodes, patient satisfaction, and adverse effects.

TARGET AUDIENCE AND PATIENT POPULATION: The target audience for this guideline includes all clinicians, and the target patient population includes adults with acute, subacute, or chronic low back pain.

RECOMMENDATION 1: Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation).

WARNING: Before following Recommendation #1,
please review the Contra-indications to NSAIDS use.

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GRADE: An Emerging Consensus on Rating Quality of Evidence and Strength of Recommendations

By Frank M. Painter|January 23, 2017|Guidelines|

GRADE: An Emerging Consensus on Rating Quality of Evidence and Strength of Recommendations

The Chiro.Org Blog

Brit Med J 2008 (Apr 26); 336 (7650): 924–926 ~ FULL TEXT

Gordon H Guyatt, Andrew D Oxman, Gunn E Vist, Regina Kunz, Yngve Falck-Ytter

CLARITY Research Group,
Department of Clinical Epidemiology and Biostatistics,
Room 2C12, 1200 Main Street,
West Hamilton, ON, Canada L8N 3Z5

Guidelines are inconsistent in how they rate the quality of evidence and the strength of recommendations. This article explores the advantages of the GRADE system, which is increasingly being adopted by organisations worldwide.

From the FULL TEXT Article

Summary points

Failure to consider the quality of evidence can lead to misguided recommendations; hormone replacement therapy for post-menopausal women provides an instructive example
High quality evidence that an intervention’s desirable effects are clearly greater than its undesirable effects, or are clearly not, warrants a strong recommendation
Uncertainty about the trade-offs (because of low quality evidence or because the desirable and undesirable effects are closely balanced) warrants a weak recommendation
Guidelines should inform clinicians what the quality of the underlying evidence is and whether recommendations are strong or weak
The Grading of Recommendations Assessment, Development and Evaluation (GRADE ) approach provides a system for rating quality of evidence and strength of recommendations that is explicit, comprehensive, transparent, and pragmatic and is increasingly being adopted by organisations worldwide

Introduction:

Guideline developers around the world are inconsistent in how they rate quality of evidence and grade strength of recommendations. As a result, guideline users face challenges in understanding the messages that grading systems try to communicate. Since 2006 the BMJ has requested in its “Instructions to Authors” on bmj.com that authors should preferably use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for grading evidence when submitting a clinical guidelines article. What was behind this decision?

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Clinical Practice Guidelines for the Noninvasive Management of Low Back Pain

By Frank M. Painter|December 2, 2016|Chiropractic Care, Guidelines, Low Back Pain|

Clinical Practice Guidelines for the Noninvasive Management of Low Back Pain: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

The Chiro.Org Blog

Eur J Pain. 2016 (Oct 6) ~ FULL TEXT

J.J. Wong, P. Côté, D.A. Sutton, K. Randhawa, H. Yu, S. Varatharajan, R. Goldgrub, M. Nordin, D.P.

UOIT-CMCC Centre for the Study of
Disability Prevention and Rehabilitation,
University of Ontario Institute of Technology (UOIT)
Canadian Memorial Chiropractic College (CMCC),
Oshawa, ON, Canada.

BACKGROUND: &nbsp Low back pain (LBP) is a major health problem, having a substantial effect on peoples’ quality of life and placing a significant economic burden on healthcare systems and, more broadly, societies. Many interventions to alleviate LBP are available but their cost effectiveness is unclear.

We conducted a systematic review of guidelines on the management of low back pain (LBP) to assess their methodological quality and guide care. We synthesized guidelines on the management of LBP published from 2005 to 2014 following best evidence synthesis principles. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane, DARE, National Health Services Economic Evaluation Database, Health Technology Assessment Database, Index to Chiropractic Literature and grey literature. Independent reviewers critically appraised eligible guidelines using AGREE II criteria. We screened 2504 citations; 13 guidelines were eligible for critical appraisal, and 10 had a low risk of bias.

According to high-quality guidelines:

(1) all patients with acute or chronic LBP should receive education, reassurance and instruction on self-management options;

(2) patients with acute LBP should be encouraged to return to activity and may benefit from paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), or spinal manipulation;

(3) the management of chronic LBP may include exercise, paracetamol or NSAIDs, manual therapy, acupuncture, and multimodal rehabilitation (combined physical and psychological treatment); and

(4) patients with lumbar disc herniation with radiculopathy may benefit from spinal manipulation.

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Low Back Pain and Chiropractic Page

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Low Back Pain Guidelines Section

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Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society

By Frank M. Painter|November 2, 2016|Guidelines, Low Back Pain|

Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society

The Chiro.Org Blog

SOURCE: Annals of Internal Medicine 2007 (Oct 2); 147 (7): 478–491

Roger Chou, MD; Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Donald Casey, MD, MPH, MBA; J. Thomas Cross, Jr, MD, MPH; Paul Shekelle, MD, PhD; Douglas K. Owens, MD, MS

Clinical Efficacy Assessment Subcommittee
of the American College of Physicians
and the American College of Physicians/
American Pain Society Low Back Pain Guidelines Panel*

Review the complete Guideline for the Evaluation and Management of Low Back Pain: Evidence Review
(482 page Adobe Acrobat file)

From the FULL TEXT Article:

The Abstract

Recommendation 1: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence).

Recommendation 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence).

Recommendation 3: Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence).

Recommendation 4: Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate–quality evidence).

Recommendation 5: Clinicians should provide patients with evidence–based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self–care options (strong recommendation, moderate–quality evidence).

WARNING: Before following Recommendation #6,
please review the Contra-indications to NSAIDS use.

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An Updated Overview of Clinical Guidelines for the Management of Non-specific Low Back Pain in Primary Care

By Frank M. Painter|October 28, 2016|Guidelines, Low Back Pain|

An Updated Overview of Clinical Guidelines for the Management of Non-specific Low Back Pain in Primary Care

The Chiro.Org Blog

SOURCE: Eur Spine J. 2010 (Dec); 19 (12): 2075–2094

Koes BW, van Tulder M, Lin CW, Macedo LG, McAuley J, Maher C.

Department of General Practice,
Erasmus MC, P.O. Box 2040, 3000 CA,
Rotterdam, The Netherlands

This review of national and international guidelines conducted by Koes et. al. points out the disparities between guidelines with respect to spinal manipulation and the use of drugs for both chronic and acute low back pain. Another review of guidelines published in June 2010 also noted a great degree of similarity between guidelines and that:“Recommendations for management of acute LBP emphasized patient education, with short-term use of acetaminophen, nonsteroidal anti-inflammatory drugs, or spinal manipulation therapy.”Although there is always a need for more evidence, the evidence over the last few years is providing much stronger support for SMT and that evidence is slowly finding its way into major clinical guidelines both in the United States and internationally.

The Abstract

The aim of this study was to present and compare the content of (inter)national clinical guidelines for the management of low back pain. To rationalise the management of low back pain, evidence-based clinical guidelines have been issued in many countries. Given that the available scientific evidence is the same, irrespective of the country, one would expect these guidelines to include more or less similar recommendations regarding diagnosis and treatment. We updated a previous review that included clinical guidelines published up to and including the year 2000.

Guidelines were included that met the following criteria: the target group consisted mainly of primary health care professionals, and the guideline was published in English, German, Finnish, Spanish, Norwegian, or Dutch. Only one guideline per country was included: the one most recently published. This updated review includes national clinical guidelines from 13 countries and 2 international clinical guidelines from Europe published from 2000 until 2008. The content of the guidelines appeared to be quite similar regarding the diagnostic classification (diagnostic triage) and the use of diagnostic and therapeutic interventions. Consistent features for acute low back pain were the early and gradual activation of patients, the discouragement of prescribed bed rest and the recognition of psychosocial factors as risk factors for chronicity.

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