There research on the effectiveness of Physical Therapy for back pain is not compelling. This presentation overviews the current evidence base and discusses the potential for classification of back pain to demonstrate stronger support for Physical Therapy.
The Specific Treatment of Problems of the Spine (STOPS) trial protocol is then presented. This study was recently completed showing moderate to strong effect sizes favouring Physical Therapy over evidence-based advice.
Note that the clinical protocol details in the presentation are examples only. For the full clinical protocol visit Physical Therapy Reviews
AProf Jon Ford’s presentation from today at the World LBP Congress in Antwerp presenting new data on the STOPS approach, introducing STOPS Plus for more complex chronic pain and comparing clinical importance with STarT Back and Cognitive Functional Therapy
A brief introduction to what Keele's Stratified care for low back pain: Subgrouping and targeting treatment for low back pain in primary care (STarT Back).
The STarT Back approach uses a simple tool to match patients suggesting with back pain to treatment packages appropriate for them. This has been shown to decrease disability from back pain, reduce time off work, and save money by making better use of health resources.
Evidence based management of osteoarthritis in primary care - Dr Jonathan Quickepcsciences
Dr Jonathan Quicke is an NIHR Academic Clinical Lecturer in Physiotherapy (Keele University). Dr Quicke presented at the 2017 Musculoskeletal Education Day, where he discussed how we can ensure that best practice can be implemented within general practice for patients suffering with osteoarthritis
There research on the effectiveness of Physical Therapy for back pain is not compelling. This presentation overviews the current evidence base and discusses the potential for classification of back pain to demonstrate stronger support for Physical Therapy.
The Specific Treatment of Problems of the Spine (STOPS) trial protocol is then presented. This study was recently completed showing moderate to strong effect sizes favouring Physical Therapy over evidence-based advice.
Note that the clinical protocol details in the presentation are examples only. For the full clinical protocol visit Physical Therapy Reviews
AProf Jon Ford’s presentation from today at the World LBP Congress in Antwerp presenting new data on the STOPS approach, introducing STOPS Plus for more complex chronic pain and comparing clinical importance with STarT Back and Cognitive Functional Therapy
A brief introduction to what Keele's Stratified care for low back pain: Subgrouping and targeting treatment for low back pain in primary care (STarT Back).
The STarT Back approach uses a simple tool to match patients suggesting with back pain to treatment packages appropriate for them. This has been shown to decrease disability from back pain, reduce time off work, and save money by making better use of health resources.
Evidence based management of osteoarthritis in primary care - Dr Jonathan Quickepcsciences
Dr Jonathan Quicke is an NIHR Academic Clinical Lecturer in Physiotherapy (Keele University). Dr Quicke presented at the 2017 Musculoskeletal Education Day, where he discussed how we can ensure that best practice can be implemented within general practice for patients suffering with osteoarthritis
MedicalResearch.com: Exclusive Interviews with Medical Research and Health Care Researchers from Major and Specialty Medical Research Journals and Meetings
Physical Therapy in the Emergency Departmentchristaloyd
At the Heart of the Rockies Regional Medical Center in Salida, CO, I got the opportunity to take the lead on doing research and analyzing data to create a presentation describing the benefits of Physical Therapy in an emergency department.
Effects of Wii versus traditional supervised exercise on the functional fitne...spastudent
Effects of Wii versus traditional supervised exercise on the functional fitness of moderately frail Chinese population- A Pilot Study
Nanyang Polytechnic
Physiotherapy
Laura Mann Center Integrative Lecture Series: Fall 2014Cara Feldman-Hunt
A Success Story: Incorporating Integrative Medicine into the Hospital and Outpatient Care
Courtney Jordan Baechler, MD, MS, Chief Wellness Officer Vice President, Penny George Institute for Health and Healing, Allina Health
Clinical prediction rule in spinal painNityal Kumar
This lecture is on spinal pain and the clinical methods used in treating the pain. Clinical prediction rules is a research method done systematically describing when to use which method of treatment approach
Evaluating a pratice guideline is essential given the rapid proliferation of them in the recent times. Here some general principles of evaluation of the guidelines are described with a guideline for panic disorder used in Australia, as an example.
MedicalResearch.com: Exclusive Interviews with Medical Research and Health Care Researchers from Major and Specialty Medical Research Journals and Meetings
Physical Therapy in the Emergency Departmentchristaloyd
At the Heart of the Rockies Regional Medical Center in Salida, CO, I got the opportunity to take the lead on doing research and analyzing data to create a presentation describing the benefits of Physical Therapy in an emergency department.
Effects of Wii versus traditional supervised exercise on the functional fitne...spastudent
Effects of Wii versus traditional supervised exercise on the functional fitness of moderately frail Chinese population- A Pilot Study
Nanyang Polytechnic
Physiotherapy
Laura Mann Center Integrative Lecture Series: Fall 2014Cara Feldman-Hunt
A Success Story: Incorporating Integrative Medicine into the Hospital and Outpatient Care
Courtney Jordan Baechler, MD, MS, Chief Wellness Officer Vice President, Penny George Institute for Health and Healing, Allina Health
Clinical prediction rule in spinal painNityal Kumar
This lecture is on spinal pain and the clinical methods used in treating the pain. Clinical prediction rules is a research method done systematically describing when to use which method of treatment approach
Evaluating a pratice guideline is essential given the rapid proliferation of them in the recent times. Here some general principles of evaluation of the guidelines are described with a guideline for panic disorder used in Australia, as an example.
Guidelines - what difference do they make? A Dutch perspectiveepicyclops
This lecture was given by Dr Raymond Ostelo of the EMGO Institute, VU University Medical Center, Amsterdam, to the North British Pain Association Spring Scientific Meeting in Edinburgh on Friday 18th May, 2007. His lecture forms part of a conference "Blurring the Boundaries - Managing Pain in Primary Care and Secondary Care".
Let's Talk Research Annual Conference - 24th-25th September 2014 (Martin Troe...NHSNWRD
"Negotiated Work Based Learning: pedagogy to up-skill Advanced Practice Physiotherapists to enhance patient journey and experience in the Emergency Department": Martin Troedel's presentation from the conference.
Professor Cindy Farquhar
Cochrane Menstrual Disorders & Subfertility Group
NZ Cochrane Branch of the Australasian Cochrane Centre
New Zealand Guidelines Group
National Women’s Health
University of Auckland
THE NEED FOR EVIDENCE-BASED PRACTICE
STEPS OF EVIDENCE-BASED PRACTICE
PICOT FORMAT IN EBP
RATING SYSTEM FOR THE HIERARCHY OF EVIDENCE: QUANTITATIVE QUESTIONS
ELEMENTS OF EVIDENCE-BASED ARTICLES
INTEGRATE THE EVIDENCE
EVALUATE THE OUTCOMES OF THE PRACTICE DECISION OR CHANGE
COMMUNICATE THE OUTCOMES OF THE EVIDENCE-BASED PRACTICE DECISION
SUSTAIN KNOWLEDGE USE
NURSING RESEARCH
TRANSLATION RESEARCH
5 PHASES OF TRANSLATION RESEARCH
OUTCOMES RESEARCH
SCIENTIFIC METHOD
CHARACTERISTICS OF SCIENTIFIC RESEARCH
NURSING AND THE SCIENTIFIC APPROACH
TYPES OF RESEARCH
TYPES OF RESEARCH APPROACH
RESEARCH PROCESS
RIGHTS OF HUMAN SUBJECT
COMPARISON OF STEPS OF THE NURSING PROCESS WITH THE RESEARCH PROCESS
Performance Improvement
Performance Improvement Programs
EXAMPLES OF PERFORMANCE IMPROVEMENT MODELS
THE RELATIONSHIP BETWEEN EBP, RESEARCH, AND PERFORMANCE IMPROVEMENT
SIMILARITIES AND DIFFERENCES AMONG EVIDENCE-BASED PRACTICE, RESEARCH, AND PERFORMANCE IMPROVEMENT
KEY ELEMENTS
An introduction on Evidence-Based Clinical Practice Guidelines in Health Care Organizations
Brief on Alexandria Center for EBCPGs in Alexandria University Hospitals, Egypt
By Dr. Yasser Sami Abdel Dayem Amer, MBBCh, MS 2013
Special Thanks to
Prof Dr Mahmoud Elzalabany
Prof Dr Tarek Omar
Prof Dr Nabil Dowidar
Prof Dr Afaf Gaber
evidence based practice is best for the people working with patients
ebp should be used by the heath care provider.
ebp based upon clinical experties
best research evidence
patient preference and values
Similar to Low back pain guidelines IFOMPT 2012 (20)
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
7. 2001 Systematic Review of
Clinical Practice Guidelines
Koes BW, Van Tulder MW, Ostelo R et al
Clinical 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
8. 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
Criteria
Target group – Languages: English,
primary health care German, Finnish, Spanish,
professionals Norwegian, or Dutch
One per country
9. LBP Guidelines 2010
13 Individual Countries
2 International Clinical Guidelines from Europe
NO
CAN FI
US
AU
NZ
10. Guidelines from 2010
1. 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)
11. 2010
An Updated Overview of Clinical Guidelines for Low Back Pain
Koes, van Tulder, Cung‐Wei,
Macedo, McAuley, Maher
Similarities:
– Diagnostic classification (diagnostic triage)
– Diagnostic and therapeutic interventions
Differences:
– Spinal manipulation and drug treatment
for acute and chronic low back pain.
12. 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 No
A
L 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 No
E Yes No
13. A Practical and Informed Approach
to Evaluate & Apply
PEDro Physio‐pedia
– http://www.pedro.org.au/ – http://www.physio‐
– Low Back Pain AND Practice Guidelines pedia.com/Lumbo‐
Pelvic_Guidelines
National Guideline Clearinghouse – Lumbo‐pelvic Guidelines
– www.guideline.gov
– low back pain Guidelines International Network
– http://www.g‐i‐n.net/
– Low back pain
National Institute for Health and Clinical Excellence
(NICE)
IFOMPT Clinical Guidelines
– www.nice.org.uk – Link to page
– low back pain
20. Evaluating Guidelines The benefits of
guidelines are only
as good as the
quality of the
practice guidelines
themselves
Agree II (2003)
Appraisal of Guidelines, Research and Evaluation
a tool that assesses the methodological rigor and
transparency in which a practice guideline is developed
www.agreetrust.org
www.agreetrust.org/?o=1397
21. Guyatt et al.
Grades of Strength of Evidence
Recommendation
A Strong evidence A preponderance of level I and/or level II studies support the
recommendation. This must include at least 1 level I study
B Moderate evidence A single high‐quality randomized controlled trial or a
preponderance of level II studies support the
recommendation
C 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 recommendation
D Conflicting evidence Higher‐quality studies conducted on this topic disagree with
respect to their conclusions. The recommendation is based
on these conflicting studies
E 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 conclusion
F Expert opinion Best practice based on the clinical experience of the
guidelines development team
22. Mexico France
USA‐15 Finland
Canada 3 Austria
UK‐6
Europe‐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
23. Additional Guidelines Since 2008
2012
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
25. Additional Guidelines Since 2008
2009
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
26. 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
28. 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
30. 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.
31. 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
34. 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
35. 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
36. 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
37. Psychologically Informed Physical
Therapy
Aims to broadly integrate psychosocial factors into clinical
practice Main & George; PTJ 2011
38. 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
40. Psychosocial factors:
Some Constructs and Measures
• Measures
– Virtually all self‐report
• Common psychosocial constructs
– Pain‐Related Fear
– Pain Catastrophizing
– Pain‐related Self‐Efficacy
– Depression
41. 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
42. 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
44. 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)
46. 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
49. 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
53. 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
54. 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
55. 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!
58. Clinical Practice Guidelines LBP
Interventions
Steve Kamper
EMGO+ Institute, VU University, Amsterdam
George Institute for Global Health, University of Sydney
National Health and Medical Research Council, Australia
59. 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?
65. 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
67. 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
68. 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
69. AGREE II*
1. Scope and purpose
2. Stakeholder involvement
3. Rigour of development
4. Clarity of presentation
5. Applicability
6. Editorial independence
* Like AGREE I except better
77. Guideline treatment for LBP
1. Reassurance and activity advice
– No serious injury, resume activities, self‐care
2. Medication
– Paracetamol, then NSAIDs, then others
3. Exercise
– Not for acutes, supervised for chronics
4. Spinal Manipulative Therapy
– Short trial in the absence of improvement
78. Other stuff
• Don’ts
– Routine x‐ray, bedrest, electrotherapies (esp.
chronics), lumbar supports
• Unclears
– Massage, acupuncture, traction
• Subgroups
– Not yet established
79. 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
80. 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
81. 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.
83. 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.
87. 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 rest
Recommended
X X X
Optional
X X X X
“Comfort is often a patient's first concern.”
http://www.chirobase.org/07Strategy/AHCPR/ahcprclinician.html
88. 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.
89. 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)
90. 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
96. 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 strong
Breen et al. Eur J Spine. 2006;15:641‐647.
98. 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.
99. 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
interventions
Breen et al. Eur J Spine. 2006;15:641‐647.
100. 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
101. More Examples (CPRs)?
• Physical • Chiropractic • Osteopathic
Therapy
• Discussion on • Not • Not
2 pages mentioned mentioned
dedicated to
this
102. 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.
103. 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
104. 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.
107. 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