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One thing that stood out to me was in the context of the guidelines at the end of the article. They stated that the guidelines initially moved away from grouping LBP by duration (acute, sub-acute, chronic) and focused more on LBP as a whole with considerations for risks of poor outcomes. We have talked during the weekend courses about the different classification systems and the pro/cons of each, including the idea that the CPRs we use may be more prognostic rather than diagnostic. I think with that in find providing guidelines with outcome risk in mind makes a whole lot of sense.
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Undoubtedly what stood out to me was the seemingly dominant volume of what NOT to do.
Specifically, we should NOT offer: routine imaging, belts or corsets, foot orthotics, rocker sole shoes, traction, ultrasound, PENS, TENS, IFC, paracetemol alone, opiods, anti-depressants, antivconvulsants, spinal injections, spinal fusion, and disc replacement.
Clearly the authors feel the need to put a halt to a lot of bad practice that must still be routinely occurring (else there would be no need to write a guideline telling us not to do these things).
While I recognize the preface of sorts that says the guideline is not law, and while I agree generally with most all their prohibitions, some of them seem quite strong and perhaps over-stated.
Can’t quote much research here, but it sure seems reasonable that an anti-depressant could be helpful as part of a multimodal approach for a patient who truly has signs of clinical depression. Perhaps the anti-depressant would help them be more willing to exercise or re-engage in typical activities that they had been avoiding as a side effect of the depression. A similar case could perhaps be made for some of the other prohibitions.
The people who wrote the guideline are much smarter than me, and I could probably count on one hand the number of times I have recommended what they specifically have said not to do (and thus I am in significant approval of the recommendation), nevertheless some aspects of their prohibition seem quite boldly stated.
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I don’t think this changes anything as far as my practice, but I like the relatively simple language that they use for their intervention recommendations, as this is intended for use by clinicians as well as patients. Unfortunately that comes with the issue you brought up Nick, that their recommendations are strongly worded. They discuss this more in the “Making decisions using NICE guidelines’ link were they say “Some recommendations are made with more certainty than others. We word our recommendations to reflect this.” Their language seems to be at odds with their stated goal of improving communication and care between patient and provider, as such a strongly worded recommendation may not be in agreement with a patient’s belief that an intervention like traction would be beneficial for their back.
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I agree with August, the traction recommendation was definitely one that I was surprised about. Especially with the rather absolute language that the authors used that August already alluded to. I certainly do not use lumbar traction frequently, but I could see a patient seeing these guidelines and being against a part of treatment that could benefit them.
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I, like everyone else liked how direct and concise the guidelines were. I think it is important that they preface the guidelines, stating that they are just that, guidelines. Some patients require more of a multimodal approach, like Nick mentioned. Some patients come in with preconceived notions about the effectiveness of specific treatments. As of recent, much of the research talks about the effects patient beliefs can have on patient outcomes. I have had a couple patients tell me about how traction helped their relative and that they feel that is what they need. I’ll always discuss the additional treatments that will supplement their care, but I do make some form of traction part of their care (manual (usually) or mechanical) if they strongly feel it will help.
I have tried to make it part of my practice asking patient’s their goals for therapy and what they feel will help. Some patients simply say “I don’t know” but some have preconceived opinions about certain therapies that should at least be addressed with the patient. Even if you end up not performing the treatment they mentioned, it should at least be discussed to help them understand why it will not be performed.
Thought on where patient beliefs fit into these guidelines?
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Justin I think that this question parallels our discussion regarding protocols in the other thread. Essentially these guidelines may generally be helpful in decreasing non-helpful or potentially negative treatments but the idea that traction absolutely, 100% of the time shoulder never be done obviously ignores the possible impact of patient belief. Similar to the protocols post-operatively, these are guidelines and each individual patient case may call for greater variation, just as Nick mentioned he has occasionally done.
Your question made me think of something though, Justin. This is a private group but one that is funded through and heavily connected to the English government, thus I would assume they have a fairly wide reach. One of their goals is to “Enable people to be accountable for their care, knowing how they will be cared for in a consistent evidence-based way, thus building patients’ confidence in NHS and social care services.” Do you think this information is reaching patients? Do you think that these guidelines are potentially changing people’s perceptions of common procedures in the low back? We talked today about the change in low back surgery in the eighties and skyrocketing costs associated, would guidelines like this from the NIH in the United States make on impact on patient beliefs and thus decrease cost?
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Interesting point, August. If that is part of the plan, I think it is great. However, I feel like this isn’t reaching many patients. Their webpage says they are “improving health and social care through evidence-based guidance”. I feel this is primarily for the providers. I did a quick “google news” search of the guidelines and only 3 articles were present. All 3 were for physiotheraist, non were news articles published in the general public’s reading material.
I think if the NIH published something like this and then a large media source wrote a few articles with the input of practitioners on pain neuroscience and healing; that potentially it could help change the publics view of the horrific disc and lower cost. But only if the public saw it. If you did a quick search of disc herniation in the google “news” tab, you would get a thousand articles of Gronk’s disc herniation, surgery, and time to return to football; only increasing the fear of people when they have an image that shows they have a disc herniation.
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Justin, I agree with your assessment. A lot of times just doing one thing that the patient likes/suggests can build that therapeutic alliance and allow you to try other treatments that they aren’t so sure of ( we’ll do traction but only if we try xyz first).
This can be a double edged sword though, like you don’t want to keep doing traction if its obviously not helping, or having the patient rely on passive techniques like hot packs or massage. But this should be easily communicated and demonstrated to the patient with test-retest and allow that buy in/therapeutic alliance
I love these recommendations “Do not offer spinal injections. Do not offer spinal fusion, Do not offer disc replacement”. Strong words that I wish more PCP’s, OrthoSurg, and NeuroSurg would read!
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I agree, Scott, that is can lead to a reliance on passive techniques. But as you mentioned it can easily be communicated to the patient through assess, treat, reassess.
For example, I am treating a pt for lateral epicondylagia. We had made improvements and he was painfree for about a week before having a setback. He came in on day and said he wanted to have ultrasound he had heard and read that it is really helpful. I explained to him the current literature on US and that previous treatments that we performed were useful. However, he was insistent and felt very strongly it would help. So, I performed US for the first time in my short career on my patient’s elbow (definitely not my proudest moment so far)…Anyways, I made sure to assess prior to treatment and reassess afterwards. No improvements were made in asterisks and he agreed that it was not a worthwhile treatment; since I had previously shown improvements with manual and exercise techniques.
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