Key Indexing Terms
|Activity||Percentage with pain interference|
|Body region||Prevalence (%)|
|Low back pain||23|
|• 40% of interviewees reported constant pain, whereas 60% were intermittent in their symptoms.|
|• The majority do not consider their current treatment adequate|
|• 76% have tried alternative therapies including chiropractic with results rated somewhat successful (50%), very successful (19%), and extremely successful (8%).|
Efforts to Improve Care Delivery
Evidence-Based Practice: Best Practices vs Guidelines
|• Measure only items that easily are feasible and ignore subtle and complex effects.|
|• Ignore context and the skill of the provider of treatment|
|• Minimally acknowledge the confounding effects of placebo healing properties|
|• Ignores patient actions, preferences, and beliefs, which may confound outcome|
|• Poorly performed RCTs are more misleading than well-performed cohort studies|
“[Evidence-based medicine] means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise, we mean the proficiency and judgment that we individual clinicians acquire through clinical experience and clinical practice.
By best available external clinical evidence, we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient-centered clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens.
Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough [emphasis added]. Without clinical expertise, practice risks becoming tyrannized by external evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best external evidence, practice risks becoming rapidly out of date, to the detriment of patients.”
“What challenges do practitioners face in blending clinical reasoning with evidence-based practice? In this article, the authors argue against basing clinical practice on narrow definitions of evidence, relying solely on experimental findings or, even more exclusively, on randomized controlled trials. Instead of defining best practice narrowly by the strength of the current empirical evidence used to guide clinical decisions, it should be defined broadly by what is the best information to use to make decisions for a given patient in a particular setting.”
“Best practice, built on a foundation of EvVP, can bridge the practice-research gap and provide a basis for researchers and clinicians to work together to translate research into meaningful practice.”
Complexity and Risk Stratification
- •Biomechanical risk factors are linked to both the incidence of first-time low back complaints, absenteeism, and subsequent episodes.
- •Psychosocial factors are more important to subsequent episodes of back pain.
- •Tissue damage can initiate a chain of events resulting in pain and activity intolerance that may affect some patients for as long as 10 years.
- •Mechanical tissue damage is often unable to be determined by modern imaging and testing procedures but are apparent on dissection/surgery.46
|Severity of symptoms|
|Leg pain > back pain|
|Increased spine flexibility|
|Reduced muscle endurance|
|Prior recent injury (<6 mo) including surgery|
|Asymmetric atrophy of multifidus up to 5 y later|
|Abnormal joint motion with or without abnormal electromyogram function of medial spine extensors|
|Poor body mechanics|
|Falling as mechanism of prior injury|
|Biomechanical||Prolonged static posture >20° (odds ratio, 5.9)|
|Poor spinal motor control|
|Vehicle operation >2 h per day|
|Sustained (frequent/continuous trunk load >20 lb|
|Materials handling (static work postures, frequent bending and twisting, lifting demands, pushing, pulling and repetitive exertion).|
|Employment history (<5 y, same employer)|
|Lower wage employment|
|Expectations of recovery|
Process of Care
If There Is no evidence?
- 1.Review and summarize available studies.
- 2.Biologic thinking may help. Is the method physiologically plausible?
- 3.Be sure that current thinking is based on valid evidence. Trust differences in subgroup result only when the intervention works unambiguously in one and fails utterly in another.
- 4.Consider costs to the patient.
- 5.Primum non nocere. When in doubt, take special care to avoid actions that might cause harm, whether it is physical, emotional, or economic.
- 6.Talk to the patient. Explain the ambiguity in the evidence and the steps you propose. Consider their preferences and beliefs.
- 7.Plan for the usual, adapt for the unusual. Algorithms are applied to usual patients and modified for unusual patients. Patient care decisions should be made on an individual basis.
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