The Value of Following Clinical Practice Guidelines for Acute Low Back PainIn today's evidence-based medicine, efforts are being made to develop standard ways to treat problems. The goal is to find treatments that yield consistent, effective results. Such a research-based treatment protocol is referred to as a clinical practice guideline (CPG). Not all conditions have clinical practice guidelines yet but there are such guidelines for the treatment of acute low back pain.
It's clear that not all patients receive care following these guidelines. So the purpose of this study was to compare results for patients who are treated in the usual manner against those who receive treatment based on the published clinical practice guidelines.
It might be helpful to define a few terms. Acute low back pain is the pain that develops early on (first four weeks). The patients in this study had low back pain lasting between two and four weeks. They ranged in age from 19 to 59. There were no patients included who had a fracture, infection, or tumor causing low back pain. Patients were randomly placed in one of two groups.
Patients in the study group (SC) were cared for following the clinical practice guidelines (CPGs). The CPGs recommend giving patients reassurance that the back pain will go away. This type of counsel is based on known research regarding the natural history (what happens over time) of acute low back pain. The proven natural history of acute low back pain is that more than 80 per cent of all adults with this problem do get better within days to weeks.
The study group also received advice to stay out of bed, stay active, and start walking. Chiropractic care (spinal manipulation) of the lumbar spine was administered two to three times a week for up to four weeks. Things that were NOT allowed included: braces or corsets, muscle relaxants or opioid drugs (narcotics), core stability exercises for the trunk or extension exercises for the back, and (as already mentioned) bed rest. They were allowed to take Tylenol (acetaminophen) for pain relief.
Patients in the second group (called the usual care or UC group) did not all get the same standard care. Some were treated by a physical therapist while others saw a massage therapist, their family doctor, or a kinesiologist (the study was done in Canada where kinesiologists who are movement experts practice).
Outcomes were measured at regular intervals (time periods) of eight, 16, and 24 weeks after treatment. Results were compared to baseline (before treatment) measurements. And improvements in pain, motion, and function were assessed at each of these points using standard tests such as the Roland-Morris Disability Questionnaire and the Short Form-36 (measures pain and physical function).
How did the two groups compare? Overall, there were more patients in the study group (those who received spinal) manipulation who did better than the patients in the usual care group. Those improvements were seen at each of the check-points but were most pronounced at the 24 week mark. An equal number of patients dropped out of each group so that aspect of the study was similar between the two groups.
uthors say the significance of this study is three-fold. First, it shows how using the Clinical Practice Guidelines already outlined for the treatment of acute low back pain really are successful (and more effective than other approaches).
Second, it is the first study to look at all the components of the Clinical Practice Guidelines (CPGs). Many previous studies have just used one or two parts of the CPGs, not the entire package. And third, the results again show physicians the importance of switching from the usual care they are prescribing to a more effective and proven approach.
This last piece (physician compliance with CPGs) is a bit of a trick. Other studies conducted by these same authors have already shown that primary care physicians are resistant to changing the way they treat patients with acute low back pain. The reasons for this attitude remain unclear at the present time.
More study is needed to find reasons for physician resistance to adopting published clinical practice guidelines for the treatment of acute low back pain when the evidence is clear about the superiority of this program over others. The authors also suggest a future long-term study to see if recurrence of low back pain occurs in one group more than the other.
Paul B. Bishop, DC, MD, PhD, et al. The Chiropractic Hospital-Based Interventions Research Outcomes (CHIRO) Study: A Randomized Controlled Trial on the Effectiveness of Clinical Practice Guidelines in the Medical and Chiropractic Management of Patients with Acute Mechanical Low Back Pain. In The Spine Journal. December 2010. Vol. 10. No. 12. Pp. 1055-1064.
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