Help! How Do I Evaluate and Apply the Numerous Guidelines for Low Back Pain; a Practical and Informed Approach for Clinicians. Elaine Lonnemann PT, DPT, MSc, OCS, FAAOMPT Tim Wideman PT Steven Kamper PT, PhD Chad Cook PT, PhD, MBA, OCS, FAAOMPT
Elaine Lonnemann PT, DPT, OCS, FAAOMPTTim Wideman PT Steven Kamper PT, PhD Chad Cook PT, PhD, MBA, OCS, FAAOMPT
Introduction to GuidelinesDefine Locate Consistencies Identify & Differences
Clinical Practice GuidelinesDesigned to support the decision‐making processes in patient care Content is based on a systematic review of clinical evidence
Clinical Practice GuidelinesTo describe appropriate care based on the best available scientific evidence and broad consensus To reduce inappropriate variation in practice To provide or promote: a rational basis for referral focus for continuing education promote efficient use of resources focus for quality control highlight shortcomings of existing literature suggest appropriate future research
Reviews of Clinical Practice Guidelines on LBP 2010 2006 2001
2001 Systematic Review of Clinical Practice Guidelines Koes BW, Van Tulder MW, Ostelo R et alClinical guidelines for the management of low back pain in primary care: an international comparison. 11 countries generally similar recommendations regarding the diagnostic classification and therapeutic interventions Consistent features early and gradual activation of patients discouragement of prescribed bed rest recognition of psychosocial factors as risk factors for chronicity Discrepancy exercise therapy, spinal manipulation, muscle relaxants, and patient information
2010 An Updated Overview of Clinical Guidelines for the Management of Non‐Specific Low Back Pain in Primary Care Koes, van Tulder, Cung‐Wei, Macedo, McAuley, Maher CriteriaTarget group – Languages: English, primary health care German, Finnish, Spanish, professionals Norwegian, or Dutch One per country
LBP Guidelines 2010 13 Individual Countries 2 International Clinical Guidelines from Europe NO CAN FI US AU NZ
Guidelines from 20101. Australia, National Health and Medical Research Council (2003) 2. Austria, Center for Excellence for Orthopaedic Pain Management Speising (2007)3. Canada, Clinic on Low back Pain in Interdisciplinary Practice (2007) 4. Europe, COST B13 Working Group on Guidelines for the Management of Acute Low Back Pain in Primary Care 1 (2004) 5. Europe, COST B13 Working Group on Guidelines for the Management of Chronic Low Back Pain in Primary Care (2004) 6. Finland, Working group by the Finnish Medical Society Duodecim and the Societas Medicinae Physicalis et Rehabilitationis Fenniae. Duodecim (2008) 7. France, Agence Nationale d’Accreditation et d’Evaluation en Sante (2000) 8. Germany, Drug Committee of the German Medical Society (2007) 9. Italy, Italian Scientific Spine Institute (2006) 10. New Zealand, New Zealand Guidelines Group (2004) 11. Norway, Formi & Sosial‐og helsedirectorated (2007) 12. Spain, the Spanish Back Pain Research Network (2005) 13. The Netherlands, The Dutch Institute for Healthcare Improvement (CBO) (2003) 14. United Kingdom, National Health Service (2008) 15. United States, American College of Physicians and the American Pain Society (2007)
2010 An Updated Overview of Clinical Guidelines for Low Back Pain Koes, van Tulder, Cung‐Wei, Macedo, McAuley, MaherSimilarities: – Diagnostic classification (diagnostic triage) – Diagnostic and therapeutic interventions Differences: – Spinal manipulation and drug treatment for acute and chronic low back pain.
T Scientific evidence is H the same. The guidelines are Recommendations measured by the E for diagnosis and same instrument? treatment should be C the same, are they?H Yes No Yes NoAL The individuals on L All the guideline Recommendations committees are E from Guidelines are similar from one N Evidence Based? committee to the G next? Yes NoE Yes No
A Practical and Informed Approach to Evaluate & ApplyPEDro Physio‐pedia – http://www.pedro.org.au/ – http://www.physio‐ – Low Back Pain AND Practice Guidelines pedia.com/Lumbo‐ Pelvic_GuidelinesNational Guideline Clearinghouse – Lumbo‐pelvic Guidelines – www.guideline.gov – low back pain Guidelines International Network – http://www.g‐i‐n.net/ – Low back painNational Institute for Health and Clinical Excellence (NICE) IFOMPT Clinical Guidelines – www.nice.org.uk – Link to page – low back pain
Physiotherapy Evidence Databasehttp://www.pedro.org.au/– pain, practice guidelines, combined with AND www.nice.org.uk low back pain
National Guideline Clearinghouse www.guideline.gov– low back pain
Guidelines International Networkhttp://www.g‐i‐n.net/about‐g‐i‐n
Evaluating Guidelines The benefits of guidelines are only as good as the quality of the practice guidelines themselvesAgree II (2003) Appraisal of Guidelines, Research and Evaluation a tool that assesses the methodological rigor and transparency in which a practice guideline is developedwww.agreetrust.orgwww.agreetrust.org/?o=1397
Guyatt et al. Grades of Strength of EvidenceRecommendationA Strong evidence A preponderance of level I and/or level II studies support the recommendation. This must include at least 1 level I studyB Moderate evidence A single high‐quality randomized controlled trial or a preponderance of level II studies support the recommendationC Weak evidence A single level II study or a preponderance of level III and IV studies including statements of consensus by content experts support the recommendationD Conflicting evidence Higher‐quality studies conducted on this topic disagree with respect to their conclusions. The recommendation is based on these conflicting studiesE Theoretical/foundat A preponderance of evidence from animal or cadaver ional evidence studies, from conceptual models/principles or from basic sciences/bench research support this conclusionF Expert opinion Best practice based on the clinical experience of the guidelines development team
Mexico FranceUSA‐15 FinlandCanada 3 AustriaUK‐6Europe‐4 39 Guidelines Norway Italy Spain Australia Netherlands New Zealand Germany UK Finland 6 4 Netherlands 3 Germany France 15 1 Austria Italy 1 Australia New Zealand
Additional Guidelines Since 20082012 ICSI: Adult acute and subacute low back pain. 1994 Jun (revised 2012 Jan). NGC:008959 Institute for Clinical Systems Improvement ‐ Nonprofit Organization. (USA‐Minn)2011 APTA‐Orthopaedic Section (2011) Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health. ACR Appropriateness Criteria® low back pain. 1996 (revised 2011). NGC:008863 American College of Radiology ‐ Medical Specialty Society MQIC: Management of acute low back pain. 2008 Mar (revised 2011 Sep). [NGC Update Pending] NGC:008744 Michigan Quality Improvement Consortium ‐ Professional Association. WLDI: Low back ‐ lumbar & thoracic (acute & chronic). 2003 (revised 2011 Mar 14). NGC:008517 Work Loss Data Institute ‐ For Profit Organization. US CA NASS: Diagnosis and treatment of degenerative lumbar spinal stenosis. 2002 (revised 2011). NGC:008766 North American Spine Society ‐ Medical Specialty Society Practice Guidelines for the management of low back pain. Mexico. Surgery and Surgeons 2011. 70; 286‐302 Clinical guidelines for the physiotherapy management of persistent Low Back Pain (LBP): Exercise ‐ Part One (1 of 2) from the Chartered Society of Physiotherapy, UK. (2009) Clinical guidelines for the physiotherapy management of persistent Low Back Pain (LBP): Exercise ‐ Part One (2 of 2) from the Chartered Society of Physiotherapy, UK. (2009) Clinical guidelines for the physiotherapy management of persistent Low Back Pain (LBP): Manual Therapy ‐ Part Two (1 of 2) from the Chartered Society of Physiotherapy, UK. (2009) Clinical guidelines for the physiotherapy management of persistent Low Back Pain (LBP): Manual Therapy ‐ Part Two (2 of 2) from the Chartered Society of Physiotherapy, UK. (2009)2010 UMHS: Acute low back pain. 1997 (revised 2010 Jan). NGC:008009 University of Michigan Health System
All guidelines recommend a diagnostic triagePatients are classified as having 1. non‐specific low back pain 2. suspected or confirmed serious pathology ‘Red Flag’ conditions such as tumor, infection or fracture 3. radicular syndrome
Additional Guidelines Since 20082009 ASIPP: Comprehensive evidence‐based guidelines for interventional techniques in the management of chronic spinal pain. 2003 (revised 2009 Jul‐Aug). NGC:007428 American Society of Interventional Pain Physicians ‐ Medical Specialty Society. IHE: Guideline for the evidence‐informed primary care management of low back pain. 2009 Mar. [NGC Update Pending] NGC:007704 Institute of Health Economics ‐ Nonprofit Research Organization; Toward Optimized Practice ‐ State/Local Government Agency ‐‐CAN NICE: Low back pain. Early management of persistent non‐specific low back pain. 2009 May. NGC:007269 National Collaborating Centre for Primary Care ‐ National Government Agency‐UK AOA: American Osteopathic Association guidelines for osteopathic manipulative treatment (OMT) for patients with low back pain. 2009 Jul. NGC:007504 American Osteopathic Association ‐ Professional Association. US ICA: Practicing Chiropractors Committee on Radiology Protocols (PCCRP) for biomechanical assessment of spinal subluxation in chiropractic clinical practice. 2009. NGC:007250 International Chiropractors Association ‐ Medical Specialty Society.2008 UK: United Kingdom, National Health Service (2008)Back Pain (Low) with Sciatica (2008)‐ UK Link CCGPP: Chiropractic management of low back disorders: report from a consensus process. 2008 Nov‐Dec. NGC:007127 Council on Chiropractic Guidelines & Practice Parameters ‐ Professional Association. US SC NASS Diagnosis and treatment of degenerative lumbar spondylolisthesis. 2008. NGC:006568 North American Spine Society ‐ Medical Specialty Society. ICA: Best practices & practice guidelines. 2008. NGC:007125 International Chiropractors Association ‐ Medical Specialty Society. US‐VA CPCA‐Diagnostic imaging practice guidelines for musculoskeletal complaints in adults ‐ an evidence‐based approach. Part 3: spinal disorders. 2008 Jan. NGC:006703 Canadian Protective Chiropractic Association ‐ Professional Association Finland: Malmivaara A, Erkintalo M, Jousimaa J, Kumpulainen T, Kuukkanen T, Pohjolainen T, Seitsalo S, O¨ sterman H (2008) Aikuisten alaselka¨sairaudet. (Low back pain among adults. An update within the Finnish Current Care guidelines). Working group by the Finnish Medical Society Duodecim and the Societas Medicinae Physicalis et Rehabilitationis, Fenniae. Duodecim 124:2237– 2239 Italy: Negrini S, Giovannoni S, Minozzi S et al (2006) Diagnostic therapeutic flow‐charts for low back pain patients: the Italian clinical guidelines. Euro Medicophys 42(2):151–170
Diagnostic Procedures should focus on – identification of red flags – exclusion of specific diseases (sometimes including radicular syndrome) – Red flags 2000‐2008 2009‐2012 age at onset (<20 or >55 years) History of Cancer or HIV significant trauma Failure to improve with conservative care unexplained weight loss No relief with bed rest widespread neurologic changes Cauda Equina signs Severe unremitting pain worsening of pain
None recommend routine use of imagingImaging recommended at the initial visit only for suspected serious pathology – (Australian, European) where the proposed treatment (manipulation) requires the exclusion of a specific cause of low back pain (French).
Imaging is sometimes recommended where sufficient progress is not being made – Time cut‐off varies from 4 to 7 weeks – Often recommend MRI in cases with red flags (European, Finland, Germany) All mention psychosocial factors Neurologic screening (not always detailed) – Strength testing – Reflexes – Sensation – SLR
Some guidelines did not distinguish between non‐specific low back pain and radicular syndrome. The Australian and New Zealand guidelines Symptom Duration – What is acute, sub‐acute, chronic & recurrent?
Yellow Flags The German guideline classifies a group of patients who are at risk for chronicity, based on ‘yellow flags’. Variation in the amount of details given about how to assess ‘yellow flags’ or the optimal timing of the assessment. The Canadian and the New Zealand guidelines provide specific tools for identifying yellow flags and clear guidelines for what should be done once yellow flags are identified.
Recommended physical examination and tests – limit the examination to a neurological screen (European) – more comprehensive musculoskeletal and neurological examination • inspection, range of motion/spinal mobility, palpation, and functional limitation
Psychosocial Risk Factors for Pain‐Related Disability and Current Clinical Practice Guidelines 1 October 2012 Timothy H. Wideman PT, PhD Post‐Doctoral Research Fellow Johns Hopkins University
Ambiguity related to psychosocial factors in current CPG• Most Clinical Practice Guidelines (CPG) recommend screening for psychosocial risk factors for pain‐related disability (e.g. yellow flags)• Considerable variance in – How recommended screening is performed – Whether interventions that target risk factors are are recommended
Objectives• Provide a brief introduction to psychosocial factors• Review how psychosocial factors are addressed in the literature• Highlight recent (exciting!) findings• Relate this ongoing research to previous Clinical Practice Guidelines
Physical Therapy versus Mental Health Most Patients with Back Pain Physical therapy traditionally focuses on biomechanical factors For most patients, recovery from back pain is influenced by both while mental health professionals focus on psychosocial biomechanical and psychosocial factors factors Main & George; PTJ 2011
Psychologically Informed Physical TherapyAims to broadly integrate psychosocial factors into clinical practice Main & George; PTJ 2011
Psychologically Informed Physical Therapy Does not aim to replace clinical expertise in psychopathology or psychiatric illness (i.e. we are not psychologists; aims to chart a middle ground) Main & George; PTJ 2011
What are psychosocial factors?• Pain‐related psychosocial factors can be broadly construed as thoughts, feelings and related behaviours that are associated with pain• Yellow (psychological), blue (occupational) and black (social systems) flags tap different aspects of psychosocial factors• Many types and measures…
Psychosocial factors: Some Constructs and Measures• Measures – Virtually all self‐report• Common psychosocial constructs – Pain‐Related Fear – Pain Catastrophizing – Pain‐related Self‐Efficacy – Depression
How do psychosocial factors relate to our clinical outcomes?• Predictors – Baseline measures that influence outcome regardless of tx. – E.g. High baseline depression predicts poor outcome following tx.• Moderators – Baseline measures that influence relationship between specific intervention and outcome – E.g. Baseline fear influence efficacy of spinal manipulation• Mediators – Treatment‐related change in measure is related to outcome – E.g. Pain catastrophizing mediates exercise and psychosocial tx. Hill & Fritz; PTJ 2011
The challenge of addressing psychological factors within clinical practice • Despite calls to address risk factors within clinical management, significant barriers exist: • Not all patients require psychosocial risk factor interventions • Assessment of multiple risk factors can be time consuming and resource intensive • Choosing a treatment that targets psychosocial factors can be challenging
New Research that facilitates the integration of psychosocial factors into clinical practice Hill et al., Lancet 2011
The STarT Back Tool: A Strategy for facilitating risk factor assessment within Primary Care• 9‐item prognostic screening tool used to quantify risk complexity of patients’ with back pain• Uses single items to represent different risk constructs (physical and psychosocial)
The STarT Back Tool: A Strategy for facilitating risk factor assessment within Primary Care
Scores on the STarT Screening Tool Can be Used to Classify Risk• Risk classification based on STarT Scores: • Low: 3 or less • Medium: 4 or more; low psychosocial risk • High: 4 or more; high psychosocial risk
Risk Stratified Care: A Strategy for Integrating STarT Back Scores into Primary Care Settings Figure from : www.keele.ac.uk/sbst/
Components of Psychologically Informed, High Risk Intervention• Goal: address pain‐related thoughts and feelings in all aspects of treatment (subjective exam to clinical intervention)• Not prescriptive with respect to psychosocial interventions • Activity monitoring and goal setting • Graded activity • Thought monitoring and restructuring Main et al., Physiotherapy 2012
Testing the efficacy of Risk Stratified Care: A double armed Randomized Controlled TrialDesign• 1500 adults with back pain • Randomized into best practice (un‐stratified) or Risk‐Stratified Care (reassurance, PT, psych‐informed PT) Hill et al., Lancet 2011
Testing the efficacy of Risk Stratified Care: A double armed Randomized Controlled Trial Unstratified Stratified Based on Risk Best Practice• MD +/‐ • PT, Psych, OT…
STarT Back RCT (Hill et al., Lancet 2011) Results (12 month follow‐up)• Patients in risk stratified group had lower levels of self‐report disability• Risk Stratified care was more cost‐effective than best practice Implications• Strategy for integrating screening and treatment of psychosocial factors into physical therapy Hill et al., Lancet 2011
Relationship Between Psychosocial Research and Current CPG• Clinical Practice Guidelines don’t reflect the detail and nuance that is reflected in primary psychosocial research (nor should they)• CPGs lag behind primary research • Research answering some of your clinical questions may not be addressed in most recent CPGs
Strategies for exploring research that is not addressed in Clinical Practice Guidelines• Remember levels of evidence • Risk stratified care currently has level 2 evidence• Can start by look for high quality reviews • Physical Therapy 2011; Volume 91; Issue 5; An excellent special issue on psychosocial factors
How can I learn more about psychosocial factors?• Take a course • Keele university offers online courses ( http://www.keele.ac.uk/sbst/ )• Come to our workshop in 200 AB at 4:15 today!
Summary• Growing literature suggests that modifiable psychosocial factors influence our treatment• We can improve treatment by adopting a psychologically‐informed approach• Investigating primary research may help answer clinical questions not addressed in current clinical practice guidelines
Clinical Practice Guidelines LBP InterventionsSteve KamperEMGO+ Institute, VU University, Amsterdam George Institute for Global Health, University of SydneyNational Health and Medical Research Council, Australia
Why are you here?• You don’t know what to do when someone with LBP pain comes into your clinic?• You want to know what you should be doing?• At some point funders are only going to pay for guideline‐based care?• You want to learn something about how to find/interpret guidelines? Why?• How do you decide what to do with your patients?
What are guidelines?• Synthesis of the best available evidence• Medline – 75 RCTs/day – 11 SRs/day• Physio (2005‐12) • 8912 RCTs • 2624 SRs
Not just an issue of volume “… before the subject could be set in a clear and proper light, it was necessary to remove a great deal of rubbish” James Lind 1753• Relevance• Quality• Effect
What are guidelines for?• To describe appropriate care based on the best available scientific evidence and broad consensus – Ensure best available care – Reduce inappropriate variation
Why are there so many guidelines?• 1 body of evidence → 39 guidelines• How can the same evidence be interpreted so differently?• Are they all necessary? Chad will solve this mystery and more
Which guideline?• Something to be aware of: Confirmation bias
What to read and what to toss• Strategies – Roll a dice – Believe everything (doesn’t solve the problem) – Believe nothing (cuts down the required reading) – Read a summary (Bouwmeester 2009, Koes 2010, Dagenais 2010, Pillastrini 2012) – Determine the quality yourself
What makes a good* guideline?* A guideline you can believe in• Methodological quality – certain rules regarding how guideline is developed and written• Analogy: RCT quality – Randomised allocation – Blinding – Follow‐up rates – Appopriate statistics and reporting
Guideline quality• Appraisal of Guidelines for Research and Evaluation: AGREE – Instrument for assessing guideline quality – 6 domains (23 items), users manual• Probably not feasible to apply yourself • Work in progress
How AGREE works• Each question (23) is scored on a scale from 1=Strongly disagree... to 7=strongly agree e.g. Q.3. (Scope and Purpose) “The population (patients, public etc) to whom the guideline is meant to apply is specifically described”• The score is a percentage of the maximum (7 on every question) in each domain• No threshold good / bad
AGREE II*1. Scope and purpose2. Stakeholder involvement3. Rigour of development4. Clarity of presentation5. Applicability6. Editorial independence* Like AGREE I except better
1. Scope and purpose• Explicit definition of: – Objectives – Health question – PopulationWhy? – So you know if you’re reading the right book
2. Stakeholder involvement• All the relevant professions represented• Includes views of patients• Target users identifiedWhy? – Minimise bias along professional grounds, ensure patient‐centredness
3. Rigour of development• How the evidence is located and synthesised• How the recommendations are linked to the evidence• External peer‐reviewWhy? – Prevent cherry‐picking from the literature
4. Clarity of presentation• Specific and unambiguous recommendations• Different Mx options clearly presented• Key recommendations easy to findWhy? – It’s no use to you if you can’t find the message
5. Applicability• Advice for translation into practice• Barriers to, and resources necessary for implementationWhy? – Recommendations are only useful if they make it to the patient
6. Editorial independence• Funding body doesn’t influence the content• Competing interests of the developers are outlinedWhy? – People have a funny way of being influenced when there is money involved (money > science)
Guidelines then and now (last 10‐12 years)• Getting better over time• Good parts: Clarity and Rigour of development• Poor parts: Stakeholder involvement, Applicability and Editorial independence• Recommendations are becoming more consistent
Guideline treatment for LBP1. Reassurance and activity advice – No serious injury, resume activities, self‐care2. Medication – Paracetamol, then NSAIDs, then others3. Exercise – Not for acutes, supervised for chronics4. Spinal Manipulative Therapy – Short trial in the absence of improvement
Other stuff• Don’ts – Routine x‐ray, bedrest, electrotherapies (esp. chronics), lumbar supports• Unclears – Massage, acupuncture, traction• Subgroups – Not yet established
Summary• Why are you are reading the Guidelines?• Offer a convenient synthesis of evidence• Not all are created equal• Be aware of your confirmation bias• Guideline quality – AGREE criteria• Guidelines are getting better and more consistent
How Low Back Pain Guidelines are Influenced by socio‐cultural, historical, economic factors, and discipline Chad Cook PT, PhD, MBA, FAAOMPT Chair and Professor Walsh University
Guidelines are Not Infallible Let’s consider how these are made • 1. Expert consensus. • 2. Outcomes based • 3. Preference based (Outcomes based combined with patient based) • 4. Evidence Based (what we are used to)Scazitti D. Evidence‐based guidelines: application to clinical practice. Phys Ther. 2001 Oct;81(10):1622‐8.
Cultural Factors• Consider Professional Culture – Surgical Checklist• Consider Socioeconomic Culture – Preference based (Outcomes based combined with patient based) – French guidelines for Physiotherapy and LBP• for subacute, recurrent and chronic low back pain: Physiotherapy is an important part of treatment, but there is no evidence in support of specific protocols specifying the number and frequency of sessions. The expert panel proposed 10‐15 sessions after the initial diagnostic assessment. These should take account of the patient’s expectations and include patient education.
U.S. Agency for Health Care Policy and Research Guidelines for Acute Low Back Pain (1994)Condition NSAIDS Tylenol Physical Thrust Shoe A “few” Agents Insoles days restRecommended X X XOptional X X X X“Comfort is often a patients first concern.” http://www.chirobase.org/07Strategy/AHCPR/ahcprclinician.html
Early Guidelines Among Practitioners was Not Popular • “The rumbling backfire is that the U.S. Government document, which is intended as a practice guideline for routine acute back care, will come to haunt us as a practice standard for all back care.”De Jong RH. Backfire: AHCPR guideline for acute low back pain. J S C Med Assoc. 1995;91:465‐8.
Economic Factors• Rarely, are cost effectiveness components considered in LBP guidelines development (Koes et al., Eur Spine J, 2010 )• Many create guidelines as a mechanism to adapt to societal, cultural, legal, or economic realities of their countries. (Dagenais et al., Spine J, 2010)
The Primary Care Provider as the Economic Gatekeeper• All guidelines are geared toward initiation of care from a primary care provider (Dagenais et al., Spine J, 2010). • That role takes different forms in different countries and cultures
Mono‐Disciplinary Guidelines • Clinical guidelines created by a specific group (e.g., physical therapists) • Mono‐disciplinary guidelines are more likely to be consensus‐based as well as biased, especially in areas where evidence is weak and discipline self interest is strongBreen et al. Eur J Spine. 2006;15:641‐647.
Mono‐Disciplinary GuidelinesBreen et al. Eur J Spine. 2006;15:641‐647.
When is it OK? • When the mono‐disciplinary guidelines is reflective of the multidisciplinary guidelines • Unique context areas • When issues not specific to multidisciplinary guidelines are factors • When more detail is needed in a given area (e.g., we recommend exercise for LBP)Breen et al. Eur J Spine. 2006;15:641‐647.
When is it not OK? • When there is no multi‐disciplinary parent • When authors or others benefit commercially or professionally from writing the guidelines • When language is used that confuses the public • When the focus is on access to care, not interventionsBreen et al. Eur J Spine. 2006;15:641‐647.
Examples• Physical Therapist • Chiropractic Guidelines Guidelines • Osteopathic (Manipulation) (Manipulation) Guidelines • Thrust manipulative and • There was little (Manipulation) non‐thrust mobilization evidence for the use • Other areas…… procedures can also be used what?? to improve spine and hip of manipulation for mobility and reduce pain other conditions and disability in patients affecting the low with subacute and chronic back, and very few low back and back‐related papers to support a lower extremity pain. A higher rating (Rating: C).Delitto et al. JOSPT. 2012;42(4):A1‐A57. http://www.ccgpp.org/delphi.pdf http://www.ccgpp.org/delphi.pdf
More Examples (CPRs)?• Physical • Chiropractic • Osteopathic Therapy• Discussion on • Not • Not 2 pages mentioned mentioned dedicated to this
Conflict of Interests • In recognition of the impact that COI have on guidelines, the Association of American Medical Colleges, the Institute of Medicine, and US, pan‐European, British, and French government authorities have included more robust policies for reporting and selection of expert committees. Jones et al. Conflict of interest ethics…….Ann Intern Med. 2012;156: 809‐816.
Why?• Conflicts of interest (62% of guidelines creators had a vested interest in the diagnostic or interventional guidelines they advocate)• Some guidelines involve findings as high as 87‐90% (Jones et al., Ann Intern Med, 2012) Trust me……• Top deficient findings in the Agree II guidelines
Example• American Pain Society • American Society of (APS) Interventional Pain Physicians (ASIPP) Chou et al.. Guideline Warfare…. J Pain. 2011;12:833‐839. Manchikanti et al. A critical review…… Pain Physician. 2010;13:E141‐E174.
Agree II Guidelines• The Appraisal of Guidelines for Research & Evaluation (AGREE) Instrument was developed to address the issue of variability in the quality of practice guidelines. http://www.agreetrust.org/about‐ agree/introduction1/
The Tool• 23 items organized into the original 6 quality domains: – i) scope and purpose; – ii) stakeholder involvement; – iii) rigor of development; – iv) clarity of presentation; – v) applicability; – vi) editorial independence. – 700 publications have used the tool